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MIDWIFERY ILLUSTRATED, 



BY 



J. P. MAYGRIER, M. D., 



PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN, AT PARIS, 
AND MEMBER OF SEVERAL SCIENTIFIC SOCIETIES. 



TRANSLATED FROM THE FRENCH, WITH NOTES, 



A. SIDNEY DOANE, A. M., M. D, 



WITH EIGHTY PLATES. 



NEW YORK: 

J. K. MOORE, UNIVERSITY BOOK STORE, CLINTON HALL. 
PHILADELPHIA : CAREY & HART. 



M DCCC XXXXH. 







I 



Entered according to an act of Congress, in the year 1833, by 

A. SIDNEY DOANE, 

in the office of the Clerk of the District Court of the Southern District of New York. 



SLEIGHT & VAN NORDEN, PRINT. 



TO 



JOHN W. FRANCIS, M.D., 

Late Professor of Obstetrics and Forensic Medicine in Rutgers Medical 
Faculty, Geneva College, New York ; Member of the Medical and Chi- 
rurgical Society of London ; of the Wernerian Natural History Society of 
Edinburgh ; of the Academy of Natural Sciences of Philadelphia ; of the 
Lyceum of Natural History of New York ; of the Literary and Philoso- 
phical Society of New York; &c, &c, &c. 

Dear Sir, 

Accept the dedication of this work as a tribute of respect for 
your profound attainments in the Science of Medicine, and particularly in 
Obstetrics, and for your exertions in the cause of Medical Literature. That 
you may long continue in your present career of usefulness, and that each 
day may add to your fame, is the sincere wish of, 

Yours, very truly, 

A. SIDNEY DOANE. 

April 2d. 



TRANSLATOR'S PREFACE. 



In presenting to the public an American edition of 
Maygrier's " JVouvelles Demonstrations d 'Accouchemens" we 
do not profess to give a complete work on Obstetrics ; we 
doubt whether this be needed, as we already possess the 
treatise of Denman with Professor Francis' valuable addi- 
tions and notes, those of Dewees, Burns, Velpeau, and 
others ; our object has been, to put within the reach of every 
student and practitioner of medicine, a book which is unique, 
and allowed by all to be extremely valuable. 

Circumstances beyond our control have prevented those 
alterations in the plates demanded by the differences be- 
tween the American and French customs, such as the posi- 
tion of the female during labor, &c. ; but these will be 
seen instantly. 

No expense has been spared to render these lithographic 
plates superior to any ever published in this country ; we 
offer them with confidence, and challenge a comparison even 
with the French originals. A few errors have occurred in 
their lettering ; the most important is upon plate L., where 



VI PREFACE. 

for " delivery of the feet in one position of the head" read, 
" in the first position of the head." These, however, will be 
corrected hereafter. 

We now commit the work to the public, hoping and 
trusting that its reception may be such as to repay, in a 
measure, the labor and money expended upon it. 



CONTENTS. 



PAGE. 

Original Preface, .......... 9 

Introduction, .......... 13 

Female Pelvis, . . . . . . . . . . 27 

Description, .......... 28 

Division and Dimensions, ........ 30 

Articulations, .......... 35 

Deformities, .......... 37 

Sexual Parts, 46 

External Organs, . . . • . . • . . 46 

Internal Organ's, ......... 52 

Uterus and its Appendages, ........ 55 

Changes in the Genital Organs, ...... 60 

Fetus and its Appendages, ........ 64 

Development of its Appendages, ...... 69 

Placenta, ........... 71 

Umbilical Cord, 72 

Nutrition and Circulation of the Fetus, 73 

Division of the Fetus, ........ 79 

Natural History of Pregnancy, . 82 

Of Touching, 94 

Of Labor, 98 

Of the Manoeuvre, 106 

Simple Manoeuvre, . . . . . . . . .108 

Complex or Instrumental Manoeuvre, . . . . . 136 

Of Delivery, 164 

Instruments used in Obstetrics, ....... 172 

Of Lactation, .......... 179 

Instruments for Natural or Artificial Nursing, . . . . 183 



ORIGINAL PREFACE. 



It must be admitted, that the study of Obstetrics has not progressed 
much in France during the last fifty years, as is incontestably proved by 
every work published on the subject, during this period. However care- 
fully authors may have endeavored to point out correctly the most re- 
markable, and the most minute particulars relating to Obstetrics, what- 
ever attention may have been given to describing the anatomical parts of 
the female and of the child, and also to demonstrating the manual of all 
difficult labors, many subjects still remain, on which our ideas are as yet 
very imperfect. A practical knowledge is not gained from books ; but it 
is by attending females in labor, and during pregnancy, that the medical 
man acquires that quickness and that experience which alone can render 
him able, and without which he will always be an unskillful practitioner, 
if not a dangerous operator. 

Having taught Obstetrics for many years, I have more than once been 
astonished at the difficulty of explaining to the pupils, who attended my 
course of lectures, certain demonstrations for which language was inade- 
quate. Struck with this inconvenience, I formed the plan of a work, in 
which I proposed to represent by drawings what seemed impossible to be 
taught without this powerful means of addressing the eye, and in that 
manner, of replacing those opportunities so often required by young phy- 
sicians in the practical study of Obstetrics. 

Several attempts were made, but they were unsatisfactory, notwith- 
standing every exertion on my part. The artists whom I consulted at 



x ORIGINAL PREFACE. 

this period, did not understand me ; those whom I employed executed 
the work intrusted to them very badly ; and I was on the point of aban- 
doning the attempt, when a happy concurrence of favorable circum- 
stances, inspired me with new courage, and I saw the possibility of at- 
taining the end proposed. The success of the undertaking hitherto has 
exceeded my expectations ; — while I am writing, the work, published by 
subscription, entitled " Nouvelles Demonstrations d? Accouchemens" 
five parts of which have appeared, progresses rapidly. It has not only 
been favorably received, but several distinguished physicians have kindly 
bestowed upon me, in the journals, such delicate commendation as I ap- 
preciate, and which I shall endeavor to merit more and more, by the 
great care I shall devote to my undertaking.* 

The plan of my work is vast, and totally different from all those which 
have hitherto appeared on the same subject. The idea of it is entirely 
new, at least in its execution. In this work, in fact, every thing in Ob- 
stetrics, which can be seen or touched, will be faithfully represented by 
engravings, in which the most scrupulous exactness will contrast with a 
perfection hitherto unequalled in this style. It will be, properly speak- 
ing, a 'pictured or graphic demonstration of Obstetrics. 

It is true that many works on Obstetrics with plates have been pub- 
lished ; but a mere glance at the plates will show their deficiency in 
execution, and that they are insufficient for the practical study of Obste- 
trics. It cannot be denied then, that this branch of science has long 
needed a work professedly on this subject, in which the author should at- 
tempt to present, by drawings and engravings, the series of objects which 
compose the practical science of Obstetrics. I know not how far this 
difficult task will be accomplished ; being the first person to form the plan, 
I may possibly fail in the end proposed. The successive and complete 
publication of the parts will alone decide this question. 

I cannot conclude this preface without thanking the different persons 
who have kindly assisted me. And first, Prof. Breschet, Chef des Tra- 
vanx Anatomiques de la Faculte de Medicine, who has placed at my 
disposal whatever might contribute to the success of my enterprise, and 

* Since this preface was written, two new editions of this work have appeared ; one, royal 
8vo., published at Brussels ; and a German translation by Siebold. 



ORIGINAL PREFACE. , xi 

whose clear and intelligent advice has been very useful. The same re- 
marks apply to Dr. Laniscard, who has executed very skillfully all the 
preparations I needed. My nephew, Dr. Ozenne, has also given proofs 
of zeal and discernment in forwarding all the details intrusted to him. 
Finally, I have thought it advantageous, and for the interest of the work, 
to take the advice of several distinguished artists who have glanced at my 
labors, and M. Desains, a pupil of David, has, among others, favored 
me with important advice. M. Chazal, draughtsman of the work, needs 
not my approbation ; his pencil and brush, the faithful interpreters of his 
talent, speak volumes in his praise. 



INTRODUCTION. 



The male and the female are formed apparently upon the 
same model, and differ, in the eyes of the multitude, only in 
their height and muscular power: it is commonly remarked, 
that the male is taller than the female; he is also the 
stronger. The knowledge of physiology generally possessed 
is confined to this point ; the enlightened observer, without 
dwelling on these superficial differences, will look further ; 
the profound study of this important subject, which he must 
necessarily make, opens to him the means of discovering 
numerous shades and modifications imperceptible at the 
first glance. Man must doubtless be stronger than woman, 
and also taller ; he, in fact, must watch over the safety and 
preservation of his family ; he must provide for the wants 
of his wife and children. But whatever may be the idea 
of beauty attached to height, this height is of no value, un- 
less all other parts of the organization perfectly accord 
with it ; for independent of the fact that the tallest men are 
not always the most intellectual, this height, when very 



xiv INTRODUCTION. 

great, so far from being an advantage, is on the contrary 
injurious : in fact, we observe that very tall individuals are 
usually thin and feeble, and are also incapable of traveling 
long distances, and of enduring excessive fatigue. It is by 
regarding the admirable models of the ancients, that we can 
gain a knowledge of the true lineaments of manly beauty : 
by looking at the finest statues of antiquity, we obtain the 
most correct, and at the same time the most noble idea of 
the happy proportions in which the Grecian statuaries ima- 
gined the real beauty of the body to consist. 

Man then, possessing all the energy of his physical pow- 
ers, and the full vigor of an enlightened reason, is the cen- 
tral point, and as it were the base on which the strength 
and the fate of the social edifice depend. It is not when 
man is emerging from infancy, when his gait is unsteady 
and he with difficulty lisps a few words, when he requires 
every assistance, that he can be left to himself, and be go- 
verned by his own powers : it is not in youth, at that truly 
brilliant period of his life, that he can take the station which 
belongs to him in the order of nature, and particularly in 
the social state: feeble, inconstant, easily seduced, and 
more easily betrayed, man, at this age, is assailed by desires 
of every kind ; he seeks pleasure in every form, and is igno- 
rant of his rights and powers ; a prey to his passions, his 
reason is not yet mature enough to conquer them, nor does 
his intellect possess the talents necessary to fulfill completely 
the duties imposed by his station. It is only when between 
thirty and forty years of age, that he is truly a man : study 



INTRODUCTION. xv 

the legislative proceedings of all nations, pursue the history 
of their progress in the arts and sciences, in their wars, and 
even in the eloquence of their tribunals, you will see that 
the public offices have been intrusted to men of this age; 
you will find that the works of genius, and the most valua- 
ble discoveries of industry, are always the fruits of mature 
life. Some rare exceptions, it is true, would seem to invali- 
date the truth of the propositions we have advanced ; but 
these exceptions, on the contrary, confirm the rule; for we are 
constantly telling that these privileged men, in whom the 
intellectual faculties are as it were prematurely developed, 
possess extraordinary talent; that they are exceptions to 
the common rule : all the details and all the traits of their 
infancy are eagerly sought after, to deduce from them this 
consequence: that nature has favored their formation, that 
she has varied from her common course, and has concentred 
in one individual a mass of intelligence generally possessed 
by several. 

Man then is not truly worthy of the name, until he has 
arrived at maturity, and can command others, as he com- 
mands himself. Master of his passions, he has at this pe- 
riod of his life all the physical and all the moral power ne- 
cessary for performing the most arduous undertakings ; he 
possesses mind enough for forming the most extensive plans, 
and those which will conduce most to the happiness of his 
fellow beings. To meditate, to conceive, and to execute : 
such are the means, such are his faculties. 



xvi INTRODUCTION. 

In this rapid glance at the rights and powers of man, we 
have not considered him in his relations with the Deity. 
This object is of great importance, as it decides his future 
destiny, and requires a plan much more vast than that 
which we have adopted. In the precepts of the Holy 
Evangelists, in the books of the Sacred Scriptures, he finds 
a rule of conduct, and an enlightened guide for his actions. 
It is sufficient to mention in this place, his rank in the order 
of nature, or in the social state, or in that of civilization. 

Let us now see how nearly the female resembles the male, 
or rather to what extent they differ : let us inquire by what 
admirable mechanism the Creator has formed two beings so 
similar in appearance, but who are in fact so different, and 
has given them tastes, inclinations and characters, which 
are, as it were, constantly in contrast and opposition : we 
shall see that the attraction which draws them to each 
other, although called into action by the same desire, does 
not rest on the same sentiment ; hence it will not be diffi- 
cult to adduce the prominent traits which distinguish the 
female from the male, and to demonstrate the great dissimi- 
larity between the male and the female ; and that the lat- 
ter is not only female in the peculiar disposition and ar- 
rangement of her genital organs, and in the essential differ- 
ences which distinguish them from those of the male, but 
in all parts of the individual ; and that she differs from the 
male, not only in the form and structure of her skeleton, 
but that the muscular, the circulatory, the nervous, the 
glandular and the cellular systems, the secretions and excre- 



INTRODUCTION. xvii 

tions of every kind, present in this respect the most perfect 
contrast, the most formal opposition. In order to be con- 
vinced of this truth, we need not wait until the female has 
arrived at the age of womanhood. Observe her from early 
infancy ; hardly can she pronounce a few words, and con- 
ceive a few ideas, than her manners are all feminine : follow 
her among male children of her age ; observe her timidity, 
her reserve and embarrassment ; when on the contrary, the 
little boys around her are bold and loud in their plays : at 
a later period, and even when the forms of both sexes are 
more developed, every one can distinguish by her gait, fea- 
tures, and even her voice, a young girl ten or twelve years 
old from a boy of the same age. If you consult their reci- 
procal tastes, how many shades and modifications are ap- 
parent. Look at the cunning of Ulysses ; when he wished 
to discover Achilles, who was concealed among the daugh- 
ters of Lycomedes, he placed arms among the jewels which 
were displayed to their eyes, to flatter their tastes, or to sa- 
tisfy their curiosity ! 

We shall not extend these remarks any further; and we 
should fail in the end proposed, if we pause to trace a more 
or less fascinating picture of the forms, graces, and attrac- 
tions of every kind, which nature has bestowed upon fe- 
males, and make this the sole object of our researches. 
Convinced that the secret end of all these advantages is the 
fulfillment of the well marked designs of nature, for the 
propagation of the species, we must not be astonished, if in 
order to accomplish this, she has bestowed upon her all the 

2 



xviii INTRODUCTION. 

power, all the magic of her seducing charms : when preg- 
nancy exists, every wish is consummated; satisfied with 
her work, nature immediately robs woman of her charms, 
and of that attraction which brings man towards her. An 
inward sentiment, a secret voice seems to say, " Respect 
her ; for she bears in her bosom the fruit of a love which 
another has shared, and with which you cannot inspire her." 
Beauty in females is not the end, but the means; and with- 
out any disrespect, it must be admitted, that all women 
cannot please by the same kind of beauty ; and that in this 
respect, tastes are as various as they are inexplicable. 
Beauty, in its strictest sense, would then be only a vain 
name, a kind of deception of our senses, a mode, a manner 
of being, the excellence of which may be extolled, and it's 
merit exalted. But this beauty which is sought for so ar- 
dently, and which is so vividly desired, would be of but 
slight advantage to those females who are so jealous of it, if 
we could only figure to ourselves that in such a woman cer- 
tain circumstances existed, which would render the act of 
generation physically impossible ; such as a defect in her 
formation, or diseases calculated to produce well-grounded 
fears, or insurmountable disgust. 

Let us not attempt to deceive ourselves ! In paying sin- 
cere homage to the female whom nature has loaded with 
her gifts, let us not despise those to whom she seems to have 
refused them. Both are equally precious in her eyes, and 
she is displeased with those only who are unfit to fulfill the 
act of generation, or who cannot perform the duties of a 



INTRODUCTION. xix 

mother. This last remark naturally leads us to a sketch 
of the duties imposed by nature on the female destined to 
become a mother. When we speak of maternal duties, we 
do not pretend to say how much it costs a mother to bestow 
upon her offspring the care required by its feebleness, and 
by its incapability of providing itself with the necessaries of 
life. 

Who, more than professional men, whose office it is to aid 
females in the most painful of their duties, can render them 
a juster tribute, and adduce more honorable examples of no- 
ble devotion, of which they daily give such touching proofs? 
No ! there is nothing more noble, more worthy of true ad- 
miration than that imperious sentiment, at once so mild and 
tender, which unites the mother to her child, and which, as 
it were, makes but one existence of two individuals, so dif- 
ferent in age, and apparently in necessities. Providence, al- 
ways wise in ordering its designs, and attentive to the wants 
of mortals, has so connected the ties which unite the mother 
to the child, and has so identified them, that we do not ex- 
aggerate in saying, that the existence of the newly born 
child is as necessary to the mother who is to nurse it, as the 
latter is indispensable to her offspring. Maternal love then 
is the invisible link which binds all living beings to their 
natal soil; a sentiment which nothing can destroy, and 
which constantly provides for the preservation of the spe- 
cies. Without this, what would become of those nations 
whom so many causes sometimes concur to destroy and ex- 
tirminate from the face of the globe? 



xx INTRODUCTION. 

Civil and foreign wars, and scourges of every kind, which 
often threaten to involve a nation in total ruin, would soon 
have swept off the last individual, if maternal love, stronger 
even than the causes which can extinguish it, had not sur- 
mounted every obstacle, had not braved every danger, to 
preserve tender and timid infancy from a death which is 
often inevitable. Man, intrusted with the great interests 
of society, is too often assailed by the desires of an insatia- 
ble ambition ; he seeks wars and contests, and confronts 
death in pursuit of a vain glory, w r hich is very frequently 
thwarted by this fury of a horrible vengeance : man, there- 
fore, is unfitted for the cares demanded by early infancy, 
is insensible to its cries, and would soon abandon it to its 
pressing wants. Thus neglected, children would perish, 
and with them the whole human race would be extinct, did 
not woman take an active and continual care of them, did 
she not consecrate to them every moment, did she not sa- 
crifice to them her whole life. Health, youth, beauty, hap- 
piness, the enjoyments of life, woman sacrifices every thing 
to her offspring. 

O cendres d'un epoux, 6 Troyens, 6 mon pere, 
O mon fils, que tes jours cofitent chers a ta mere ! 

ANDROMAQUE. 

This feeling, however, which is so vivid and so imperious 
that we are obliged to call it sublime in females, does not 
belong to the human race alone ; it appears as energeti- 
cally and as strongly in animals, who may be said, in cer- 



INTRODUCTION. xxi 

tain cases, to display resources which strike with astonish- 
ment and admiration even the most indifferent persons. The 
females of wild animals are usually less ferocious than the 
males, but become much more furious when their young 
are born, and during the whole period of lactation. How 
plaintive the cries, and how touching the moans of the fe- 
male birds, when a cruel hand has stolen the nest which 
contained their young offspring ! 



Glualis populea mcerens Philomela. 

Et moestis late loca questibus implet. 

VIRGIL. 

Numerous facts in regard to maternal love in the human 
species might be mentioned; we, however, shall confine 
ourselves to the following. In one of the last actions of 
the exterminating war waged by the Turks against the 
Christians in the East, the inhabitants of a village, yielding 
to numbers, but not destitute of courage, took the generous 
resolution of burying themselves under the ruins of their 
habitations, and of terminating the contest only with life ; 
fearful of seeing their wives and children fall into the hands 
of their cruel enemies, they entertained, in their despair, 
the frightful thought of destroying them all, and of perish- 
ing themselves afterward, involving the Turks in their ruin. 
Their wives were apprised of this horrible plan, and by a 
supernatural effort forgot their own danger, to think only 
of their children. They instantly took a resolution which 



xxii INTRODUCTION. 

must have sprung from an excess of maternal love : they 
demanded arms, stood at the side of their husbands, and all, 
animated by a warlike spirit worthy of so good a cause, 
prostrated their barbarous enemies in the dust. 

Sa mere . . . Ah ! que l'amour inspire de courage ! 
Q,uels transports animaient ses efforts et ses pas ! 
Sa mere ! . . . elle s'elance au milieu des soldats : 
" C'est mon fils ! arretez ! cessez, troupe inhumaine ! 
C'est mon fils ! dechirez sa mere et votre reine, 
Ce sein que l'a nourri, ces flancs que l'ont porte." 

MEROPE. 

Numerous traits which I could adduce, would all prove 
this incontestable fact, that woman, destined by her peculiar 
nature to bear within herself the elements of a new being, 
and thus to contribute to the reproduction of the species, 
can have no greater happiness than that of devoting all her 
time to the preservation of her offspring, so weak, and 
apparently so delicate. But so far from complaining of the 
state of feebleness of early infancy, we must, on the con- 
trary, admire the wisdom of Providence, which has made 
this obligation imposed on woman, the powerful bond 
which unites the whole chain of beings, and thus causes 
a succession of generations, while the invariable order is 
uninterrupted; and, as one of the greatest writers of the 
past age has observed, " If man was born tall and strong, 
his height and force would be useless until he had learned 
to use them : they would be injurious, by preventing others 
from assisting him; and, left to himself, he would die of 



INTRODUCTION. xxiii 

wretchedness before knowing his wants. We complain of 
the state of infancy : we do not see that man would have 
perished, if he had not been born a child." 

Of all the maternal duties, there is no one more sacred 
than that which imposes on mothers the obligation of 
nursing their children. Here every thing concurs to ac- 
complish the design of nature : not to mention the inward 
sentiment, so mild, and at the same time so imperious, 
which acquaints the mother with the cares due to her 
child, with that involuntary claim which in spite of her, 
obliges her to turn her tender regards towards the little 
creature which nestles in her bosom, the changes of every 
kind in her organization demonstrate its imperative neces- 
sity. What in fact, can be more admirable than the inva- 
riable order in which the new functions are performed, by 
the aid of which, the mother, satisfied of the existence of 
her child, may without effort, present it with nourishment 
as abundant as it is salutary ? What is more ingenious, 
and at the same time more simple, than the flow of milk. 
At the first cry of the child, at the slightest touch of the 
lips, at the least caress, the mother is agitated : a slight 
shiver, which seems to begin at the feet, passes with the 
rapidity of lightning over the whole body, and stopping at 
the bosom, produces upon it the most lively impression. 
At that moment, the parts are evidently swelled, and a 
slight tension is perceived there : the mammae are soon 
filled with an abundant secretion of milk, and if the mother 



xxiv INTRODUCTION. 

does not immediately give the breast to her child, the milk, 
impatient of remaining in the canals, jets forth, and nothing 
can arrest its course. 

We ought not, in this place, to omit mentioning, that how- 
ever sacred may be the obligation of nursing her child, 
however imperious may be the laws of nature on this sub- 
ject, we are often obliged to bend before other laws which 
are no less commanding. All females do not live in fields : 
customs, manners, and the mode of living in great cities, 
are so many obstacles which very often oblige females to 
employ wet nurses, when it would be pleasant for them to 
fulfill the duties of mothers. It is in vain that Aulagelle 
among the ancients, that Buffon and Rousseau among the 
moderns, have spoken of these duties with all the warmth 
of the most persuasive eloquence ; in vain have they ex- 
tolled the sweets, the transports, of maternal love ; in vain 
have they cursed those women who freed themselves from 
the obligation of nursing their children ; necessity, stronger 
than the eloquence of these great authors, has made every 
thing bend to its law. Not to mention in this place those 
females whose numerous occupations prevent them from 
discharging the maternal duties, how many circumstances, 
such as locality, convenience, health, or even character and 
vicious inclinations, may prevent a mother from nursing 
her child. A prudent and enlightened physician should 
then request that the charge of nursing may devolve on 
another when he thinks that this duty may be attended 
with inconvenience or danger. 



INTRODUCTION. xxv 

To medicine alone belongs the incontestable right of 
directing females in the exercise of this most important 
function : to that alone belongs the honor of marking out, 
in this respect, the conduct they must follow, and the 
precautions they must take. Ye tender wives, ye sensible 
and courageous mothers, whatever may be your charms, 
whatever may be the homage paid to you by flattering, 
perhaps by deceitful tongues, finally, whatever may be the 
vortex of pleasure in which you seek to dissipate the hap- 
piest periods of your life, believe in disinterested advice ; 
maternal love can alone impart to you unclouded happi- 
ness, and remorseless pleasures ! It is the powerful bond 
which intimately unites the wife to her husband ; it is a 
source of delicious enjoyment to the mother ; it sweetens 
the pains of life : finally, it is the true mode of preserving 
perfect health, and of guarding against the cruel sufferings 
and pains which often afflict those insensible to the voice of 
nature, or even those who for powerful reasons do not 
suckle the offspring bestowed on them by Heaven. 



MIDWIFERY ILLUSTRATED. 



OP THE FEMALE PELVIS, 



CONSIDERED IN ITS RELATIONS WITH 



THE PRACTICAL SCIENCE OF OBSTETRICS, 



The pelvis considered generally, is only one division of 
the skeleton, the study of which belongs to that of osteo- 
logy; bat in its relations with parturition, the pelvis is a 
part of a series of organs, all which series concurs to ac- 
complish the generative functions. We proceed to examine 
it in this last point of view : its study is very important ; as 
this study alone can make known to us the real mechan- 
ism of parturition, and the greater or less difficulties which 
may sometimes render it complex. 

In studying the pelvis, we must attend: 1st, to its descrip- 
tion ; 2d, to its general and special division, and to its di- 
mensions ; 3d, to its connections ; 4th, to its anomalies, or 
to the deviations in its formation. 



28 MIDWIFERY ILLUSTRATED. 

I. DESCRIPTION OF THE PELVIS. 

The pelvis is a bony cavity, situated below the vertebral 
column, and above the lower or abdominal extremities : it 
is composed of four bones, viz. the sacrum, the coccyx, 
and the two iliac or coxal bones. 

Sacrum. This bone is unmated, pyramidal, and triangu- 
lar; it is flattened from before backward, and forms the 
posterior part of the pelvis. Its base is turned upward, and 
articulates with the last lumbar vertebra. Their union 
forms forward a remarkable prominence, termed the sacro- 
vertebral prominence or angle (the Promontory of Meckel). 
Its apex is turned downward and articulates with the 
coccyx. 

Its anterior, internal or pelvic face is concave, and pre- 
sents two ranges of foramina, through which pass the ante- 
rior branches of the sacral nerves ; in the natural state, the 
rectum is situated on this face. 

The external, posterior, or spinal face is convex, and pre- 
sents several tubercles, to which tendinous, aponeurotic and 
ligamentous parts are attached. We also remark in it two 
ranges of foramina, through which the posterior branches 
of the sacral nerves emerge. 

The two sides of the sacrum present above, at their 
upper part, an articular impression, exactly like that of the 
iliac portion of the corresponding coxal bone ; at its lower 
part, the large and small sacro-sciatic ligaments are 
inserted. 

Coccyx. This unmated bone is situated at the posterior 
part of the pelvis, below the sacrum, to which it is attached 
as an appendix. Its anterior and concave face looks to the 
inner side of the pelvis, and supports the end of the rectum ; 



MIDWIFERY ILLUSTRATED. 29 

its posterior and convex face is situated directly below the 
integuments, and presents nothing worthy of remark; its 
base is turned upward, and articulates with the sacrum ; its 
apex is loose, and is enveloped by the surrounding soft 
parts. 

The coccyx is formed of three distinct pieces, which are 
very movable on account of the peculiar arrangement of 
their articulation. 

Iliac or coxal hones. These two irregular bones form the 
sides and the anterior part of the pelvis. Their external 
face, the femoral, presents above a broad surface, termed the 
gluteal region ; below, there is a cavity for the head of the 
femur ; still lower and forward is the obturator or oval fo- 
ramen. The rest of this external face presents nothing 
remarkable. 

The internal face, the abdominal, presents above a broad 
concave surface, termed the internal iliac fossa, on which 
the iliacus internus muscle is situated ; below, a prominent 
line which proceeds obliquely from behind forward; still 
lower, the opening of the obturator or oval foramen ; behind 
this foramen, a broad surface, which forms an inclined plane 
on which the head of the fetus glides during parturition. 

The circumference commences above and forward by the 
anterior and superior spine of the ilium ; following it back- 
ward, we find the crest of the same bone in the form of the 
letter S ; farther backward, the great ischiatic notch ; be- 
low, the ischiatic spine and the small ischiatic notch ; en- 
tirely below, the tuberosity of the ischium ; reascending 
forward, the ascending branch of the ischium and the de- 
scending branch of the pubis ; above, the symphysis pubis, 
which is from eighteen to twenty lines high, and from six to 
eight broad ; anteriorly, the spine of the pubis and its hori- 



30 MIDWIFERY ILLUSTRATED. 

zontal branch, at which place we observe the ilio-pectineal 
eminence, and more posteriorly, a groove on which the 
united tendons of the psoas and iliacus muscles glide. 

It is necessary in anatomy, and particularly in obstetrics, 
to divide the iliac or coxal bone into three parts ; which 
are, the ilium above, the pubis below and forward, and the 
ischium below and backward. But the lines of demarka- 
tion are visible only in very young subjects; at a later pe- 
riod, all the parts of the bone are so blended that they 
cannot be distinguished. (See Plate II. Figure 3.) 

II. DIVISION AND DIMENSIONS OF THE PELVIS. 

Before passing to the general division of the female pel- 
vis, we must point out the differences which distinguish it 
from that of the male, and those points in which they both 
differ from that of the fetus. By looking at the first two 
comparatively (see PL II. Fig. 1 and 2) it is easy to see that 
the pelvis of the female is lower and broader than that of 
the male, and that the arch of the pubis particularly, in the 
first, is much more open and rounded than in the second ; # 

* Professor Francis {Francis 1 Denman, 3d edition, p. 95,) has stated very 
lucidly, the distinctive marks of the male and female skeleton, which occur chiefly 
in the pelvis. He says, "The pelvis of the female is less strong, less thick, and 
contains less osseous matter than that of the male. In the female, the long 
diameter of the brim of the pelvis is from side to side ; in the male it is from 
before backv/ard ; in the female, the brim is more of the oval shape, in the 
male more triangular : in the female the ilia are more distant ; the tuberosities 
of the ischia are also more remote from each other, and from the os coccygis ; 
and as these three points are further apart, the notches between them are con- 
sequently wider, and there is of necessity a considerably greater space between 
the os coccygis and pubes than in the male. The female sacrum is broader 
and less curved than in the other sex. The ligamentous cartilage at the sym- 
physis pubis is broader and shorter. In consequence of the cavity of the pelvis 
being wider in women, the superior articulations of their thigh-bones are fur- 



MIDWIFERY ILLUSTRATED. 31 

*so likewise in comparing the pelvis of the two adults with 
that of the fetus, we see that this latter is remarkable for 
its great length, and also for its extent from before back- 
ward, which is much greater than from side to side, while 
the contrary is the case in the pelvis of an adult. The rea- 
son of this is that the sacrum is deficient : the different 
pieces of which it is afterwards to be composed have, at 
this early period, only the usual breadth of the other 
vertebrse. 

The whole pelvis is divided into the large and small pel- 
vis. The large is very flaring, and occupies all its upper 
part. It is formed posteriorly by the last two lumbar verte- 
bra, which must be left in place when we wish to preserve 
the pelvis for the study of obstetrics. We observe anteriorly, 
a great fissure, occupied in the recent state by the parietes 
of the abdomen, which being flexible and very elastic, yield 
with facility to the development of the uterus during 
gestation. 

The sides of the large pelvis are formed by the iliac por- 
tions of the coxal bones. Above, it looks into the abdomen ; 
below, it blends with the small pelvis, from which it is 

ther removed from each other, which circumstance occasions their peculiarity 
in walking : they seem to require a greater effort than men to preserve the 
centre of gravity when the leg is raised. The greater distance between the 
anterior and superior spinous processes of the ilia necessarily increases the 
length of Poupart's ligament forming the crural arch ; on which account less 
resistance being made to the abdominal viscera, females are more subject to fe- 
moral hernia than males. Soemmering has remarked, that the angle of union 
of the ossa pubis is in the male from 60 to 80 degrees, whereas in the female 
it is 90 degrees. 

According to the most accurate calculations, the mean height of the male, 
at the period of maturity, appears to be about five feet eight and a half inches r 
that of the female seems to be about five feet five inches ; and the length of 
the different regions proportionally less than in the male. A well-formed pel- 
vis is generally allowed to have a circumference equal to one-fourth of the 
height of the female." 



32 MIDWIFERY ILLUSTRATED. 

separated only by the slightly contracted opening, termed 
the superior or abdominal strait. 

The small pelvis, or the pelvis properly so called, is only 
that kind of canal through which the fetus passes, with 
greater or less pain, during parturition. It is narrow at its 
entrance and its termination, and the intermediate space 
presents a kind of cavity, the cavity of the pelvis, in which 
the head of the child, while passing, performs certain very 
remarkable motions, which we shall mention hereafter. 

Although the general figure of the cavity is not exactly 
quadrilateral, we may, however, distinguish in it four sides. 
The posterior plane is formed entirely by the sacrum and 
coccyx, and is the longest ; the anterior plane, which is the 
shortest, presents the symphysis pubis above, and the arch 
of the pubis below. The lateral planes are formed princi- 
pally by the inner face of the ischia. These four planes, 
or sides, are arranged so that the anterior and posterior are 
nearer each other above than below, while the contrary is 
true of the lateral planes. This arrangement explains the 
necessity of the rotatory motion performed by the head of 
the fetus, while passing through the cavity of the pelvis, on 
a knowledge of which is founded the knowledge of the 
true mechanism of parturition. 

The upper of the two openings of the lower pelvis, or 
the brim, is termed the superior or the abdominal strait : 
the lower opening, the outlet, the inferior or perineal strait. 
As the study of the dimensions of the two straits of the 
pelvis, is undoubtedly the most important thing in the 
practical knowledge of obstetrics, we proceed to treat of 
them very particularly. 

Dimensions of the pelvis. Authors have endeavored to 
determine the figure of the superior strait, and it has been 



Pli. II. 




-Idult Male Plelris. 




^rlalt Pemale Pelvis. 




-Pewits oP £h& full grown Petus. 



PL. III. 




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pl.iv; 




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MIDWIFERY ILLUSTRATED. 33 

compared sometimes to a circle, sometimes to an oval, and 
sometimes to a curvilinear triangle. We prefer, however, 
to ascertain its form by determining the dimensions of the 
pelvis, which are as follow. 

In the superior or abdominal strait, or the brim, we gene- 
rally admit three diameters : 1st, an antero-posterior or 
sacro-pubic diameter, (L. diametros minor, s. recta, s. con- 
jugates), extending from the centre of the promontory of 
the sacrum, directly to the upper and central part of the 
symphysis pubis; in a well-formed pelvis, this diameter 
measures from three and a half to four inches : 2d, a trans- 
verse or iliac diameter, (L. cliametr. major, s. transversalis.) 
the direction of which is from right to left, and reciprocally 
from one of the sides of the abdominal strait to the opposite 
side, cutting the preceding at a right angle ; this diameter 
measures five inches ; 3d, an oblique, or cotylo-sacro-iliac 
diameter, of which there are two : one extends from the 
inner part of the right cotyloid cavity, to the sacro-iliac 
symphysis of the left side, the other from the inner part of 
the left cotyloid cavity to the sacro-iliac symphysis of the 
right side : their direction is obliquely from before back- 
ward. This diameter measures four and a half inches. 
(See PL IV. Fig. 1.) 

The inferior or perineal strait, the outlet, has two dia- 
meters only : 1st, an antero-posterior or conjugate diameter, 
(D. conjugata) which extends from the lower part of the 
symphysis pubis to the extremity of the coccyx. In its 
usual state, this diameter measures only four inches ; but, 
during parturition, the child's head presses the coccyx back- 
ward, and thus the antero-posterior diameter of the inferior 
strait is enlarged at least one inch. (See PL III. .Fig. 
2. a. a.) The dimensions of the transverse diameter never 



34 MIDWIFERY ILLUSTRATED. 

change. It extends from one of the tuberosities of the 
ischium, directly to that of the opposite side. This 
diameter is generally four inches. 

Direction and axes of the Pelvis. If we consider the 
situation of the pelvis in a female standing erect, supposing 
all the adjacent soft parts to be removed, it is easily seen 
that the plane of the symphysis pubis is much lower than 
that of the sacro-vertebral prominence. This depression 
gives an idea of what is commonly understood by the direc- 
tion of the pelvis, the inclination of which varies from thirty- 
five to forty-five degrees, taking the sacro-vertebral angle as 
the point of departure of the horizontal line. That being 
given, a line drawn from about the centre of the cavity of 
the sacrum, passing through the centre of the brim of the 
pelvis, and going directly to the umbilicus of the pregnant 
female, forms exactly the axis of this strait. On the other 
hand, a second line drawn from the upper third of the 
sacrum, and passing through the centre of the distended 
vulva, forms the axis of the inferior or perineal strait. 

It follows, from our remarks, that the head of the child 
does not proceed exactly in a straight line when passing suc- 
cessively through the different points of the pelvis, but on 
the contrary in a curve, which continues even through the 
external organs of generation, long after the head has passed 
through the centre of the outlet, as is exactly represented 
in PI. VI. Fig. 2. 

This motion does not occur in most animals, and particu- 
larly in the mammalia ; in them, the two straits of the 
pelvis have one and the same axis, which is parallel also 
to the axis of the body ; the direction of the latter is 
horizontal. (See PL III Fig. 3.) 



MIDWIFERY ILLUSTRATED. 35 



III. ARTICULATION OF THE BONES OF THE PELVIS. 

The articulations of the bones of the pelvis resemble 
those of the bones of the same species in other parts of the 
animal economy. They are the mixed kind of some 
authors ; the synarthrosis, or rather the amphiarthrosis of 
the ancients, and the articulation by continuity, of the 
moderns. 

The articulations of which we are about to treat, and 
which are more generally termed symphyses, are, that of 
the ossa pubis, that of the sacrum with the iliac bones, that 
of the sacrum with the coccyx, and the articulation of the 
last lumbar vertebra with the sacrum, to which must be 
added the description of the ligamentous and membranous 
parts which assist to increase the strength of the former. 

Sy?nphysis Pubis. In order to have a correct knowledge 
of the different symphyses of the pelvis, they must be stu- 
died in the recent state. In the recent state, the symphysis 
pubis is formed by a fibrocartilaginous substance of a 
prismatic or triangular figure, which is perfectly included 
in the space between the articular surfaces of the ossa 
pubis, with which it is connected. This substance is white, 
elastic, thicker anteriorly than posteriorly, and is rendered 
firm in its position by very many ligamentous and aponeu- 
rotic parts, and also, in its lower portion, by a special cruci- 
form ligament. In a first confinement, the head of the fetus 
sometimes vibrates upon its sharp and flexible edge, before 
emerging freely from the external organs of generation. 

The tissue, in the centre of the triangular cartilage, is 
evidently less dense, and more flexible : hence, the possi- 
bility of a slight but real motion in the symphisis pubis ; 



36 MIDWIFERY ILLUSTRATED. 

this has been observed particularly in females who have 
died in the latter periods of pregnancy. The sensation 
also of weariness and fatigue complained of for a long time 
after a tedious and difficult labor, also depends on this.* 

Sacro-iliac symphyses. As the mechanism of the sacro- 
iliac symphyses is not the same as that of the symphysis 
pubis, a difference naturally exists in their mode of articu- 
lation. The sacrum is articulated with the iliac bones by 
the ragged and uneven arrangement of the articular sur- 
faces which we have mentioned above. Each of these sur- 
faces is incrusted with a thin and compact layer of cartilage, 
which, by means of its numerous points of contact, causes 
the intimate connection of the bones, but is not entirely 
sufficient for their articulation, without the aid of strong 
and numerous ligaments which entirely surround it, 
particularly at its posterior part. 

Sacro-coccygeal symphisis. The sacrum is connected with 
the coccyx, and the different parts of the latter are united 
with one another by a fibro-cartilage of a soft spongy tex- 
ture, and by some longitudinal ligamentous fibres. The 
extreme mobility of the coccyx, and the facility with which 
it is pushed backward while the head is passing through 
the outlet, depend upon this favorable arrangement. 

Sacro-vertebral symphysis. This articulation resembles 
that of the other vertebrae with each other, It is interest- 
ing in obstetrics, only on account of the relations of the 

* The eminent German anatomist, Meckel, considers this flexibility or soft- 
ening of the cartilage, as occurring normally in every state of pregnancy, and 
states that u the softening begins to take place in the eighth month of preg- 
nancy, that is, precisely at that time when the lower region of the genital 
organs begins to enlarge and to secrete a great quantity of mucus." 

Meckel's Anatomy, vol. 2. p. 45. 



MIDWIFERY ILLUSTRATED. 37 

last lumbar vertebra with the sacrum, and the more or less 
prominent angle formed anteriorly by these two bones. 

Besides these different modes of union, which serve to 
render the bones of the pelvis firm, there are also some 
w T hich are not used for the same purpose, but which circum- 
scribe the lower part of the pelvis, and which have the 
solidity, but not the weight and size of bones. There are 
four of these ligaments, two on each side ; they are termed 
the sacro-iliac ligaments. 

IV. DEFORMITIES OR DEVIATIONS IN THE FORMATION OF THE PELVIS. 

By deformities or deviations in the formation of the pel- 
vis, we understand every species of alteration in its natural 
and regular form, the consequences of which may have a 
more or less remarkable influence on the fortunate termi- 
nation of parturition. 

Authors apply to the pelvis the terms deformed and mal- 
formed with indistinctness ; there is, however, a wide dif- 
ference between them : a pelvis may be deformed, while its 
conformation is regular, and it may have a malconforma- 
tion, although it be not deformed : it is important to es- 
tablish this distinction. In fact, a deformed pelvis is 
always more or less injurious to the termination even of 
natural labor; it either quickens its progress when the 
pelvis is too large, or retards it very much when the pelvis 
is extremely narrow. The deformities of the pelvis regard 
its dimensions : its malconformation affects its form. A 
malformed pelvis is not always injurious to the termination 
of labor : a deformed pelvis, whether malformed or not, 
always prevents it to a greater or less extent. 



38 MIDWIFERY ILLUSTRATED. 

A pelvis may be deformed, either by being too large or 
too small. (See PL V. Fig. 1 and 2.) In the former case, 
the life of the child may be much endangered by a too rapid 
delivery, as a species of asphyxia most generally attends its 
too hasty expulsion. The mother even is not always 
exempt from accidents during gestation, or during the 
expulsion of the fetus. The extreme obliquity of the 
uterus during pregnancy, its prolapsus, and its inversion 
after parturition, most generally result from an excessive 
size of the pelvis. However fearful an excess in the size of 
the pelvis may be for the mother and child, its narrowness is 
still more to be dreaded, when this narrowness is so great 
as not to allow the labor to be terminated by nature alone. 

Narrowness of the pelvis is generally attended with a 
malconformation, and the great difficulties of certain unna- 
tural labors must be attributed to this circumstance. The 
narrowness of the pelvis unattended with malconformation, 
may generally be measured and calculated by certain in- 
struments which we shall mention hereafter. This is not 
the case with its malconformation, the nature of which 
cannot always be determined during the life of the female. 
(See PL V. Fig. 3.) 

The direction of the vertebral column may be perfectly 
natural in a female whose pelvis is excessively deformed : 
on the other hand, it may vary more or less, and present 
very evident deformities in a female where the pelvis is 
well formed (See PL VI. Fig. 3.) ; hence the practitioner 
should be very careful in his diagnosis, as it is very easy to 
be deceived in choosing the means indicated for terminating 
the labor. 



MIDWIFERY ILLUSTRATED. 39 

Whatever may be the degree of alteration in the form of 
the pelvis, its narrowness varies in different individuals : 
it may be only a few lines in the diameter of a pelvis 
which is normal in other respects, and the termination of 
the labor may not be impeded. In other cases, on the con- 
trary, the narrowness may exist to such a degree, that the 
opening between the straits may be only a few lines, in 
which case the termination of the labor in the natural way 
is physically impossible. 

The narrowness of the pelvis affects sometimes the 
superior or abdominal, and sometimes the inferior or pe- 
rineal strait. In the former case, the contraction always 
occurs in the antero-posterior or sacro-pubic direction : 
in the second case, in the lateral or ischiatic direction ; 
so that wiien no very remarkable deformity exists, the en- 
largement of one of these straits is always inversely as the 
contraction of the other. (See PL VI. Fig. 1 and 2.) 

The most common causes of the deformity or malconfor- 
mation of the pelvis, generally act with a certain degree of 
intensity, only during the early periods of life. Scrofula, 
so common among those nations who live in the temperate 
parts of Europe, may be considered as the most common 
and the most general cause. The symptoms attendant upon 
the first dentition in young girls of the higher class in life 
in large cities, the ignorance and forgetfulness of the laws 
of Hygeia in the working and indigent classes, add singu- 
larly to the cause first mentioned : hence why labors are 
generally less difficult among females who reside in the 
country than in those of cities ; the latter require the 
resources of art more frequently. 



40 MIDWIFERY ILLUSTRATED. 

The following is a scale of the proportions proper to 
direct the young practitioner in the study and practical 
application of the means to remedy the difficulties resulting 
from the defects or malconformation of the pelvis. 

When the pelvis measures four, three and three quarters, 
or three and a half, inches, the labor does not require the 
assistance of art ; nature will complete it alone. When 
the pelvis is from three and a half to three inches, or two 
and three quarter inches, and one or two lines less, the 
forceps must be applied. 

When the pelvis is two and a half, tw-o and a quarter, 
two inches, or one inch and three quarters, the operation of 
symphysiotomy is necessary. 

Whenever the anteroposterior diameter of the pelvis is 
less than one inch and three quarters, the child cannot be 
born through the vagina : we must resort to the Cesarean 
operation. 

Mode of determining the defects of the pelvis in a female 
while living. The necessity for examining the pelvis exists 
not only in pregnant females, before and during labor, in 
order to determine to what extent the pelvis may be de- 
formed, but it is often required in young females, in regard 
to whose formation, parents having well-grounded fears, 
request the opinion of an enlightened physician, to know T to 
what extent their children, if married, may hope or fear to 
become mothers. Whatever else may be the circumstances 
under which physicians are consulted, the means are the 
same, the mode alone of their application differs. 

Before proceeding to a more particular examination, let 
us take a general view of the formation of the person in re- 
gard to whom we are consulted. If the female in fact be 




EL. VI 



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MIDWIFERY ILLUSTRATED. 41 

short, the arms very long compared with the rest of her 
body, the chin long, the eyes large and blue, the skin white, 
and the flesh soft, these circumstances are calculated to 
lead us to fear some deformity of the pelvis : in such a 
female the legs are generally crooked, and her form is not 
straight. By placing one of the hands flat upon the poste- 
rior part of the sacrum, and two or three fingers of the 
other on the anterior part of the symphysis pubis, we may 
also determine, from the short distance between these oppo- 
site regions, when the pelvis is narrow, and even distinguish 
its deformity by the propinquity and the unevenness of the 
anterior superior spines of the iliac portion of the coxal 
bones. But we must admit, that however great our care in 
the first examination, we must not depend solely upon these 
simple measurements, if we would determine exactly the 
real degree of alteration in the pelvis. 

Several instruments have been invented to ascertain in 
the living female the real dimensions of the pelvis : only 
two, however, have been approbated by the profession; 
these are, the callipers and the pelvimeter of Coutuli. The 
first is applied externally, the second is introduced into the 
internal genital organs of the female. They are both 
figured in PI. VII Fig. 2. 

Callipers. This instrument is composed of two movable 
arms, which are rounded externally, and when placed upon 
the female open sufficiently wide to embrace the haunches : 
when used carefully its application is easy and convenient. 
Each arm terminates in a button, and is perforated at its 
posterior part, through which a graduated arc or scale can 
be passed at pleasure. The object of this scale is to indi- 
cate the extent of the parts contained and passed over by 



42 MIDWIFERY ILLUSTRATED. 

the two arms when they are properly used. The instru- 
ment should be applied upon the naked body, or over the 
chemise when the female objects to being exposed. One of 
the buttons should be placed against the anterior and supe- 
rior part of the symphysis pubis, the opposite arm on the 
tubercle of the last lumbar vertebra. It is very important 
to determine with care the exact spot where the posterior 
arm is applied, since as this operation is generally performed 
upon females in whom the pelvis is more or less defective 
and malformed, we may easily be deceived without this pre- 
caution, and be led into errors fatal both to the mother 
and child. 

If the callipers are well applied, the scale points out, 
without removing the instrument, the extent of the parts of 
the female included in the space between the two buttoned 
arms : if we now subtract the thickness of the symphysis 
pubis, w T hich is six lines, and that of the upper part of the 
sacrum, which is two inches and a half, the remainder is 
the exact measure of the space between the sacro-vertebral 
angle, and the internal or posterior part of the symphysis 
pubis. 

The advantages of the application of the callipers seem 
incontestable ; they however present several inconveniences 
which cannot be avoided, if we should confine ourselves to 
their employment alone. 

Independent of the difficulties which sometimes attend 
its application, and the errors into which we may conse- 
quently fall from a want of experience, we cannot deny 
but that it gives strictly only the thickness of the pelvis, 
considered from before backward, when covered by the soft 
parts : this mechanical agent, applied with the utmost pos- 



MIDWIFERY ILLUSTRATED. 43 

sible precision, indicates neither the peculiar nature of the 
deformities of the pelvis, nor the degree of deviation of the 
sacro-vertebral prominence, nor the other peculiarities un- 
favorable to the termination of parturition, which may exist 
in the cavity of the pelvis. 

Pelvimeter. These considerations doubtless led Coutuli to 
invent a new instrument, termed by him the pelvimeter. 
This instrument consists of two parallel branches, which 
slide with facility upon each other, and which terminate by 
two raised extremities : it is introduced within the vagina, 
and is directed towards the sacro-vertebral prominence. 
When there, we draw towards us the upper branch, the end 
of which stops on the inside of the symphysis pubis : the 
portion of this branch drawn outward is graduated into 
lines, so as to give the exact measure of the true distance 
which the inner branch passes over, and consequently of 
the sacro-pubic diameter. This is the great advantage of 
the pelvimeter, and the object which the inventor expected 
to attain : but this instrument, although ingenious in its 
combinations, presents numerous inconveniences, which 
have caused it in a great measure to be abandoned: these 
are, the difficulty and the danger attending its introduction. 

If it be demonstrated, that the inconveniences attending 
the employment of the two instruments which we have de- 
scribed, do not allow our researches to be confined to their 
application alone, when we foresee the necessity of employ- 
ing artificial means to terminate the labor, the safety of the 
female and that of the child then require a stricter exami- 
nation, which shall be perfectly certain, and which shall in- 
sure the practitioner the utmost safety in regard to the re- 
sults of his investigations. This can be attained by touch- 



44 MIDWIFERY ILLUSTRATED. 

ing : by introducing the index finger of one hand into the 
vagina, the practitioner can acquire all the knowledge rela- 
tive to the examination he proposes to make ; he is not only- 
able with his finger to reach the sacro-vertebral angle, and 
thus to determine the real extent of the sacro-pubic diame- 
ter, but he has also the advantage by this means of passing 
over the whole extent of the cavity of the pelvis, and of de- 
tecting and of becoming acquainted with the different kinds 
of alterations, and with all the obstacles which may more 
or less oppose the termination of the labor. 

In order to make this examination properly, the female 
should stand erect, her shoulders resting against a solid 
plane ; the index finger of one hand is then carefully intro- 
duced into the vagina, directed obliquely upward and 
backward towards the sacro-vertebral prominence, and 
rested on its centre. We then raise the radial side of the 
finger towards the arch of the pubis, pressing slightly upon 
its cutting edge, and make a mark or depression with the 
nail of the index finger of the other hand upon that which 
is introduced, as near as possible to the body of the pubis ; 
we now withdraw the finger, and measure the extent be- 
tween the small mark mentioned above, and the end of the 
finger, by placing it upon a scale. (See PL VIII. Fig. 
2 and 3.) 

From the sum total of the portion of the finger intro- 
duced, we must subtract six lines for the thickness of the 
symphysis, and two or three lines for the degree of obli- 
quity the finger has in passing through the interior of the 
pelvis. The remainder then forms the exact measure of the 
space between the sacrum and the symphysis pubis, and 



MIDWIFERY ILLUSTRATED. 45 

gives the true measure of the antero-posterior or sacro- 
pubic diameter. 

Some inexperienced practitioners may sometimes be fear- 
ful, if they cannot reach the sacro-vertebral prominence, and 
thus perhaps be very much at a loss to form an opinion in 
regard to a female submitted to them for examination. Let 
them be assured that the pelvis of the female in this case is 
not deformed, and that the antero-posterior diameter is large 
enough to allow the passage of a child's head of common 
dimensions. 

The mode of determining the deformities of the inferior 
or perineal strait is not very difficult : in most cases it will 
only be necessary for the female to lie on her back, her legs 
flexed on her thighs, which are separated and raised towards 
the abdomen : thus the two tuberosities of the ischium are 
remarkably prominent, and it is easy to perceive the dis- 
tance between them. If we wish for more exact results, 
the distance between the two tuberosities may be measured 
by the rounded extremities of a pair of common compasses, 
and then by applying the compasses to a scale, we may 
estimate within half a line, the extent of the ischiatic or 
transverse diameter of the lower strait. Here there is no 
necessity for subtracting ; all the extent embraced between 
the legs of the compasses should be estimated, and this 
forms the absolute measure of the diameter. * (See PL 
VII Fig. 4.) 

* While this sheet was going to press, one of my pupils, Mr. Martin, 
showed me an instrument for measuring the pelvis, termed a pelvigraph, which 
is worthy the attention of practitioners. Its plan is very ingenious, and its 
description and figure will be given hereafter. 



OF THE SEXUAL PARTS OF THE FEMALE, 



CONSIDERED IN THEIR RELATIONS WITH THE GENERATIVE FUNCTIONS, 



AND 



THE PRACTICAL SCIENCE OF OBSTETRICS. 



The genital organs of the female should be studied in 
two different points of view: 1st, in a state of rest or va- 
cuity ; 2d, in that of action or fulness. Hence the nature 
of the changes in the sexual parts of the female, during 
the performance of the generative functions, and also 
the order in which these changes are developed, cannot be 
well understood without an exact knowledge of the same 
parts in a state of rest or emptiness. They should be 
described w T ith care : we proceed to this subject. 

The genital organs of the female have generally been 
divided into external and internal parts. Although there is 
no reason in anatomy for this distinction, it will be 
preserved for the convenience of demonstration. 

I. EXTERNAL GENITAL ORGANS OF THE FEMALE. 

The study of the external genital organs of the female 
requires no special preparation. We have merely to look 
at the external labia when slightly separated, to perceive 
successively all the objects about to be described. 



MIDWIFERY ILLUSTRATED. 4? 

When the external parts are in the natural state, and 
perfectly approximated, we perceive only the external labia 
and the fissure between them ; (See PL IX. which repre- 
sents with great precision, and most scrupulous fidelity, 
these parts in their most natural state), but if they be 
slightly separated, we then observe with facility all the ob- 
jects forming what is termed the vulva or the pudendum. 
(See PL X.) 

The vulva is composed of the mons veneris, the external 
labia, the clitoris, the vestibule, the internal labia, the mea- 
tus urinarius, and the canal of the urethra, the hymen, the 
fourchette, the frenum, the carunculse myrtiformes, the 
perineum, and the entrance of the vagina. 

Mons veneris or Penil. This is a rounded and more or 
less prominent eminence, situated in front of the pubis ; 
it is covered with hairs at the age of puberty, which vary 
in number, length, and color, according to the age of the 
female, although their color generally resembles that of the 
hairs of the head. 

The mons veneris is formed of a great quantity of fatty 
cellular tissue, directly covered by the skin. It also 
possesses arteries, veins, lymphatics, and nerves. 

External labia. These are two in number, and form the 
sides of the fissure which they circumscribe : they extend 
from the mons veneris to the perineum. Their extremities 
unite, and form the commissures of the external labia, 
which are thicker above than below. They are generally 
very large in females who are fleshy. Their external face 
is brown: it is formed by a prolongation of the skin of the 
inner and upper part of the thigh, on which are numerous 
sebaceous follicles. 



48 MIDWIFERY ILLUSTRATED. 

The inner face is reddish, smooth, and shining : it is covered 
by the mucous membrane, and is connected in its whole 
anterior portion with the inner face of the external labium 
of the opposite side, and more deeply with the internal labia. 

The external labia are composed of a great quantity of 
cellular tissue, similar to that of the mons veneris. We 
also find in them some cellulo-fibrous bands, some distinct 
fibres of the constrictor vaginae muscle, and a great number 
of vessels of all kinds. 

Clitoris. This is a tuberculous oblong body, which varies 
in size : it is situated at the upper and middle part of the 
vulva, above the vestibule, and between the internal labia, 
and is most generally concealed by the external labia. 
This body is sometimes so large in certain females, that it 
resembles in some measure the penis of the male. This 
circumstance may deceive some persons, and lead them 
to believe that the two sexes may be united in the same 
individual. 

The clitoris is composed first, of a species of rounded 
glans, which is imperforate, and surrounded with a mem- 
branous fold formed by the mucous membrane, similar to 
the prepuce ; this is continuous laterally with the nymphse : 
second, of a cavernous body attached by two roots, like that 
of the male, to the descending branches of the pubis, and 
supported from the symphysis by a kind of suspensory 
ligament, which is flattened from right to left. 

The structure of the clitoris is similar to that of the 
penis, with this difference, however, that the spongy tissue 
of the first is less abundant and more compact. 

Internal labia or nymphce. By this term we understand 
two membranous and erectile folds, w T hich are flattened 
transversely.; they are of a vermilion red, are thicker in the 



PL. XI. 




cc. Bladder. 

3. Uterus. 



1%. 



*.2. 




V* 



ag/&7i<z 



. 



Internal Oro^a^r^s, 



Pli.XIl. 




F&.2. 




~ - , 




InterruzJ' 0T£rv&n<$ 



_L Uhra. c I ' 



&</-? 



3. 





/¥,Xl// 



/#&;<//,>. 




jfitetevdel rh2M TIT 




Fu/.l. 



Interior of Iks TTlervc*s 



F&2. 




Mra.'t'vScJizm tyJP- (i , JuAnscn JV.Y. 




Vertical section of The Uterus. 



pjl.xv: 




J^alloniasn tube/ 




-^SkI 



Jallcpvcun, py^earvancy. 



3%&3. 




0va>ry. 



Fi&4. 




/Sectwn of the Ovary: 



J?r<ut/r<- & -Litkoy. fy 2>.G Jc/nu-m sY.Y 



MIDWIFERY ILLUSTRATED. 49 

centre than towards the extremities, and arising from the 
prepuce of the clitoris. The internal labia are very near 
in this place, but separate continually, and terminate on the 
inner surface of the external labia, they becoming much 
thinner towards the centre of the edge of the orifice of the 
vagina. The nymphee are very much developed in females 
at birth, and are generally of a moderate size in adult 
women. Their size and length vary much ; these variations 
depend on age, on the race, and the diseases which may 
affect them. In some cases it becomes necessary to divide 
them : this operation, which is by no means unfrequent, 
does not seem to be attended with very bad consequences. 
The internal labia are composed, each, of a portion of the 
mucous membrane of the vulva folded upon itself, so as to 
give rise to two folds, between which is a slight layer of 
erectile tissue. A great number of vessels of every kind, 
which ramify infinitely in their surface, also enter into their 
composition. 

Vestibule. By the term vestibule, we understand the 
slightly depressed triangular space, which is situated be- 
low the clitoris, above the urethra, and between the nym- 
phee. In some females who are not strictly attentive to 
cleanliness, we find a quantity of sebaceous matter, which 
may deceive and lead one to suspect the presence of 
syphilitic disease. 

Meatus urinarius, and urethra. The term meatus urina- 
rius is applied to the opening at the base of the vestibule, 
the edge of which is surrounded by a sac formed by the 
mucous membrane of the vulva, which is always more pro- 
minent below than above. The urethra is the canal which 
proceeds from the meatus urinarius into the bladder. It is 
not remarkably broad ; it is only about one inch long : it is 



50 MIDWIFERY ILLUSTRATED. 

situated a little obliquely upward and backward, below 
the symphysis pubis, above the vagina, with which it is in- 
timately united, and is continuous forward and downward 
with the meatus urinarius, and behind and above with the 
bladder. Hence the canal of which we are speaking, de- 
scribes a slight curve, which is concave upward, on the side 
of the pubis, and convex downward, on the side of the va- 
gina. The interior of the urethra is covered by the mucous 
membrane, and is reddish : this membrane forms a great 
number of very prominent longitudinal folds, and we ob- 
serve, especially at the base, a great many mucous lacunce. 
Externally, it presents a slight layer of spongy tissue ; but 
there is no body corresponding to the prostate gland of 
the male. 

Hymen. The hymen, termed by some authors the virginal 
or vaginal valve, is a more or less extensive membranous 
fold, varying in figure, formed by the mucous membrane of 
the vulva, just when it enters the vagina. It is situated at 
the posterior and lateral part of the external orifice of the 
vulvo-uterine canal, which it closes more or less perfectly. 
The hymen is generally very thin; sometimes, however, it 
is very thick : its form is most generally semilunar ; some- 
times oval from right to left, or almost circular, with an 
opening in the centre ; and in some very rare cases, it has 
the latter form, but presents no opening ; it is then imper- 
forate : when this is the case, it prevents the discharge of 
the menses. Some celebrated accoucheurs assert, that they 
have found the hymen so strong that it prevented the termi- 
nation of the labor: to facilitate which, they have been 
obliged to make a circular incision in it. The absence of 
this part, always supposes the action of some mechanical 
cause which has broken it. Nurses, by roughly rubbing 



MIDWIFERY ILLUSTRATED. 51 

the sexual parts of female infants with coarse towels, and 
ulcerations of these parts also, may alter, and even destroy, 
this emblem of virginity ; when the hymen does not exist, 
females are accused of having been deflowered upon too 
slight grounds. 

Carunculce myrtiformes. This term is applied to small, 
flat or rounded reddish tubercles, of various sizes, formed, 
as is generally thought, of the remnants of the hymen, but 
attributed, by Professor Beclard, to the existence of the 
mucous membrane, enlarged in this place. It would follow, 
from the latter opinion, that the caruneulse myrtiformes ought 
always to exist before the rupture of the hymen; but all 
authors agree, that they are seen only in females who are 
not virgins. Be this as it may, they are from two to five or 
six in number : they vary also in color and consistence in 
different subjects. They may be of a vermilion red, livid or 
pale, firm or soft. From all these remarks, we must be cau- 
tious in admitting that the presence of the hymen may 
always be regarded as a certain sign of virginity, since its 
absence is not always an evidence of defloration. 

Fossa navicularis. The navicular fossa is a small cavity 
situated at the posterior part of the external orifice of the 
vagina, between the caruneulse and the posterior commis- 
sure of the external labia, termed the fourchette or frenum. 
It is very difficult, in a first confinement, for this latter 
part to resist the efforts made by the head to escape from 
the external parts; but its rupture is unattended with bad 
consequences': we cannot say the same when the rupture 
involves a greater or less portion of the perineum, as we 
shall mention hereafter. 

Perineum. This is the space situated between the pos- 
terior commissure and the anus. It is divided lengthwise 



52 MIDWIFERY ILLUSTRATED. 

into two equal parts, by a kind of suture, termed the raphe : 
it is shorter and narrower in the female than in the male, 
and hence is very much exposed to laceration, during the 
first confinement, especially if the female intrusted with the 
management of the head, does not sustain it carefully, by 
pressing it upward with the hand on an inclined plane, and 
thus pushing it towards the centre of the distended vulva, 
in order that it may escape freely through this opening. 



II. INTERNAL ORGANS OF GENERATION. 

The internal organs of generation are, the vagina, the 
uterus, and its appendages. The study of these different 
organs necessarily demands preparations, not required for 
that of the external parts : we think we have performed a 
task as happy in its results as it was difficult to*execute, in 
plates XI. XII. XIII. and XIV n which present views of 
these organs, perhaps never seen before. 

Vagina, or vulvo-uterine passage. This is a cylindrical 
and membranous canal, situated in the smaller pelvis, 
extending a little obliquely from below upward and from 
before backward, from the neck of the uterus which it 
embraces, to the centre of the vulva, at the base of which it 
opens : this canal is slightly curved on itself, so as to be 
concave forward on the side of the bladder, and convex 
backward on the side of the rectum : we also remark, that 
its anterior wall is shorter than the posterior. The vagina 
is narrower at its centre than at its two extremities. When 
not distended, it is from five to six inches long. 

In the vagina we distinguish an external and an internal 



MIDWIFERY ILLUSTRATED. 53 

surface, and two extremities ; one of which is superior, the 
other inferior. 

Superiorly, the external surface is covered above and 
behind by the peritoneum : before and below, it is united to 
the bladder and the canal of the urethra by cellular tissue, 
which is more compact the lower it is examined : behind 
and below, it is connected with the rectum, to which it is 
united by some cellular tissue of the same character : on 
the sides, the external surface corresponds above to the 
broad ligaments of the uterus and to the ureters, and below 
to a very great quantity of cellular tissue, which separates 
it from the levatores ani muscles, and in which the vessels 
of the uterus and bladder and the umbilical artery ramify, 
but particularly the vessels and the nerves of the organ 
which we are describing. 

The internal surface is contiguous to itself. Its parietes 
are constantly covered with a more or less dense layer of 
mucus : farther, its dilatation is proportional to the fre- 
quency of coition, and the number of accouchments. We 
distinguish in it an anterior and a posterior longitudinal 
line : they are more apparent towards the vulva than 
towards the uterus ; the first, which is always more pro- 
minent than the second, forms a large tubercle below the 
orifice of the urethra; we also distinguish there a great 
number of transverse wrinkles, which disappear on the 
sides, and which are much more prominent and more 
numerous near the vulva than near the uterus, where they 
seem to assume all directions : these transverse wrinkles 
are cut at a right angle by longitudinal ridges : be this as 
it may, all are formed by the mucous membrane which 
lines the vagina. 



54 MIDWIFERY ILLUSTRATED. 

The upper extremity of the vagina presents a well 
marked fissure, which has the form of a crescent : it is 
attached around the upper part of the neck of the uterus, a 
little higher behind than before, so that this special union 
of the vagina to the neck gives rise to a cul-de-sac, which is 
very distinctly marked posteriorly. The wall of the vagina 
is very thin in this place ; hence, in applying the forceps, 
the accoucheur should be very careful not to carry the 
blade of the instrument to this part, lest he should rupture 
it, and cause other serious accidents. 

The lower extremity is continuous with the vulva, and 
at its deepest part slopes from above downward and from 
before backward. 

The vagina is formed internally of a mucous membrane, 
which is evidently the continuation of that which lines the 
vulva, and which is continuous with that of the uterus ; it is 
red, and the color »of vermilion below : it becomes whitish or 
grayish above : it often presents posteriorly bluish or livid 
spots, which are more or less irregular. We also remark a 
great number of pores which are only the orifices of its 
lacunae. This membrane becomes thinner successively in 
going from the vulva to the neck of the uterus : finally, it is 
covered, in its whole extent, with a very distinct epidermis, 
with an erectile spongy tissue, which forms on the outside, 
near its lower extremity, a layer an inch broad, and from two 
to three lines thick : its texture is dense and compact, its color 
grayish or bluish. This tissue becomes much thinner above ; 
it however re-ascends to the uterus, and seems to be con- 
tinuous with the proper tissue of the womb : this tissue 
is commonly termed the retiform plexus. Finally, a small 
circular fasciculus is formed by some muscular fibres, on 



MIDWIFERY ILLUSTRATED. 55 

the outside of the spongy tissue just mentioned: this is 
the constrictor vaginae muscle, which also receives vessels 
and nerves : the former come from the hypogastric vessels, 
the latter are given off by the sciatic plexus. (See the 
successive plates.) 



UTERUS AND ITS APPENDAGES. 

The description of the uterus and its appendages com- 
pletes the history of the genital organs of the female. The 
appendages are first, the broad ligament which encloses the 
uterine or Fallopian tube in the anterior segment, and in 
the posterior the ovary and its ligament : second, the round 
ligament. 

Uterus. The uterus is a hollow viscus, situated in the 
cavity of the smaller pelvis, between the bladder and the 
rectum, above the vagina, and below the circumvolutions of 
the small intestine. Its figure is conical, resembling a pear 
flattened on its two opposite faces, more prominent poste- 
riorly than anteriorly, rounded at its base, and truncated at 
its summit. Its entire length is three inches ; it is two 
inches broad at its upper part, while its breadth at the 
lower part is only one ; it is about one inch thick. 

We distinguish in the uterus a base, a body, a neck, and 
a cavity ; the base is that portion of the uterus which rises 
above the insertion of the tubes, and is only a few lines 
high : its form is rounded, and it is covered in its whole 
extent by a prolongation of the peritoneum. The body is 
the largest part of the uterus, and includes that portion of 
the organ extending from its base to its neck : its form is that 
of a triangle, the upper two angles of which correspond to 



56 MIDWIFERY ILLUSTRATED. 

the insertion of the tubes, which communicate, in this place, 
with the cavity of the uterus. The lower angle blends 
with the neck. Externally, the anterior and posterior 
faces of the body of the uterus are covered in great part 
by a prolongation of the peritoneum : internally, these two 
faces form the parietes of its cavity. 

The neck of the uterus is the elongated portion seen 
below the body; it passes into the vagina, and occupies its 
upper part : it is from ten to twelve lines long, from six to 
eight lines thick from before backward, and from eight to 
ten broad : it is cylindrical, compressed from before back- 
ward, and slightly enlarged at its central portion : it com- 
municates in the cavity of the uterus by an opening termed 
the upper, internal or uterine orifice. The corresponding 
extremity in the vagina forms a prominent part, perforated 
in the centre by an opening which is termed the external, 
inferior, or vaginal orifice. This opening is transversely 
elongated and closed perfectly, in females who have borne 
no children ; but it becomes rounded and sloping in 
those who are mothers. It is bounded by two rounded 
lips ; of these the anterior is thicker, the posterior thinner : 
this opening is termed by authors, the os tincce : the neck is 
encircled in its whole extent by a cavity which is more 
contracted at its two extremities, and a little broader at its 
centre. (See PI XIII. Fig. 2.) 

The cavity of the uterus is flat and triangular; it is not 
very extensive, and is scarcely large enough to admit a 
small bean : the upper two angles present the very narrow 
orifices of the Fallopian tubes, the lower angle communi- 
cates with the cavity of the neck. (See PL XIII Fig. 1.) 
Sometimes this opening is divided by a perfect septum; 
hence the possibility of superfetation, several cases of 



PX. XVI 



■^'■''■'■■' 




Fc 



£f/ 



-DoiMz Zf&rus. 




1*0.2. 



Vce-w of th&Rotuid LipeMnente. 



'V /.tihccr-,i -Ae.j/ /,:, iAml-tr: 



1/ is lory of the> Feliw. 



PL. XVII. 



IS day j. 



F«?,2. 



Zl decys, 




R#.3. 



4f days. 




Fig.Jf-. 



2 -months. 




Ficf.5, 



4 -months, 




3 months 



My. 6. 




lie? s. 



5 nhonftha. 




jva&zr 



/%, 



y- 



/' '// ;/. 




SJfiw/St 



&¥ 



Si?*. 




PLX2X 



&Zerzs?sz &zcis-'. 



& 



1 

I 




**~ ff*ei*e. &l. &&A. tflT 



TL. XX. 



Fij.i. 




Dcuble Placentas. 



*kf:2. 




ZfoU>iZica£ <3c?7v& . 



2/rrxu/Ti <$c Jj-ciU. fy %.£. John t on W.Y. 



MIDWIFERY ILLUSTRATED. 57 

which are known. Fig. 1. PI. XVI. presents an instance 
of this kind, which we detected in an uterus brought to 
the lecture-room for our lectures on obstetrics. 

The uterus presents externally a serous membrane, a 
prolongation of the peritoneum, which covers its upper 
three-fourths : internally, it seems formed by a continuation 
of the mucous membrane which lines the vagina. Professor 
Chaussier doubts the existence of this membrane : the 
reasons with which he supports his opinion appear unan- 
swerable. This learned physiologist says, that a simple 
accidental coagulated concretion, has been mistaken for the 
mucous membrane of the uterus ; but this membrane pos- 
sesses none of the characters of the mucous membrane 
which lines the vagina. (See his letter to Mad. Bocvin.) 
The proper tissue of the uterus, then, is that portion of 
this organ which is under the serous membrane : this tissue 
is dense, elastic, and grayish white : its density increases 
near the Heck, where its grayish tint diminishes : the ar- 
rangement of its component fibres cannot be distinguished 
in any part ; and it would be difficult, by examining this 
tissue in the natural state, to form an idea of the changes 
produced in it by pregnancy. 

The arteries of the uterus are given off by the hypogastric 
arteries : they are tortuous and small, while the organ is 
inactive; but they often enlarge during pregnancy: the 
veins accompany the arteries. 

The lymphatic vessels of the arteries are so numerous, 
and their dilatation during pregnancy is so remarkable, that 
we should be led to believe the uterus to be formed by 
them entirely ; they come from the hypogastric plexuses. 



58 MIDWIFERY ILLUSTRATED. 



APPENDAGES OF THE UTERUS. 

The peritoneal membrane, after enveloping the upper 
three- fourths of the uterus, forms before and behind this 
organ some slight folds which are termed its anterior and 
posterior ligaments : it is reflected also on its sides, and 
forms there a broad fold, termed the broad ligament, 
which incloses the Fallopian tubes, and the ovaries. 

Fallopian tubes. These are cylindrical canals, which 
extend from the upper angles of the uterus, with which 
they communicate, to the sides of the superior or abdo- 
minal strait ; they are about five inches long. Of the two 
extremities of the tube, the internal, which is very small, 
passes through the tissue of the uterus, and opens into the 
cavity of this organ by an opening so narrow as hardly to 
admit a bristle ; the external extremity is termed the infun- 
dibulum, or the fimbriated extremity: it is loose, and 
fringed, and is generally inclined toward the ovary, to 
which it is attached by one of its longest fringes. Although 
it is not easy, generally, to show the duct of the tube, yet 
this can be accomplished by a little patience and skill. 
(See PL XV. Fig. 1.) 

The tubes are composed of a common external mem- 
brane, which passes to them from the peritoneum, and of 
two special membranes, an external and an internal : the 
external is thicker, denser, whitish, and contractile, 
although we cannot discover in it any muscular fibres : the 
internal is thinner and softer, and seems to belong to the 
mucous membranes : near the fimbriated extremity is a 
small portion of spongy tissue. 



MTDWIFERY ILLUSTRATED. 59 

The vessels of the Fallopian tubes come from the hypo- 
gastric vessels. 

Ovaries. These parenchymatous organs are vascular, 
oval, and slightly compressed on their two opposite faces ; 
their color is a pale red ; they are rather dense, about the 
size of a small pigeon's egg^ and are situated in the 
posterior folds of the broad ligament. 

In the ovaries we distinguish two extremities; one is 
external, in which one of the principal fringes of the Fallo- 
pian tube is inserted, by which the Fallopian tube is 
brought upon the ovary, which it embraces in almost its 
whole extent, at the moment the ovum is impregnated : the 
internal extremity is continuous with a thin fibro-vascular 
cord, which terminates in the substance of the uterus, 
behind but a little below the insertion of the tube : this 
cord is termed the ligament of the ovary; it is situated like 
the latter organ, in the broad ligament, and occupies its 
posterior wing : it is solid, and presents no trace of a duct. 
{See PL XII. Fig. 1.) 

The ovaries present on their surface rounded promi- 
nences, separated by slight grooves : we sometimes observe 
in them small cicatrices or wrinkles, in young females who 
have borne children. {See PL XV Fig. 3.) 

The peritoneum directly covers the whole external sur- 
face of the ovaries, except at the place where they adhere 
to the broad ligament. 

It is difficult to determine the nature of the parenchyma 
of which the ovary is formed : however, when this body is 
ruptured, or divided longitudinally {see PL XV. Fig. 4), we 
observe from fifteen to twenty cellular, vascular lobules 
and small rounded vesicles, the size of a grain of wheat : 
these vesicles are filled with a colorless or yellow albumi- 



60 MIDWIFERY ILLUSTRATED. 

nous fluid; this may be seen better by dividing them 
carefully with the point of a pair of small scissors. 

The ovaries receive their vessels from the spermatic 
vessels^ their nerves are very small, and come from the 
renal plexuses; the lymphatic vessels communicate with 
those of the kidneys. 

Round Ligaments. These are cellulo-vascular cords, 
which extend from the uterus to the internal and upper 
part of the thighs : they come from the sides and the ante- 
rior and superior parts of the uterus, before and below the 
insertion of the tubes, and thence proceed from below 
upward, and from within outward, towards the inguinal 
ring, through which they pass, immediately expand, and 
terminate in the cellular tissue of the groins, the clitoris, 
and the external labia. (See PL XVI. Fig. 2.) 

These cords are whitish and dense, slightly flattened, and 
thinner at their centre than at their extremities : they are 
composed of filamentous cellular tissue, of blood vessels, 
and of lymphatics : their uses are unknown : towards the 
middle of gestation, however, they sometimes swell, become 
painful, and thus take part in that species of general 
turgescence, with which the pregnant female is at this 
time affected. 



GLANCE AT THE CHANGES IN EACH OF THE PARTS COMPOSING THE 
GENITAL ORGANS OF THE FEMALE, AT DIFFERENT PERIODS OF HER 
LIFE, AND AT THEIR USES. 

The end proposed by nature in the composition and the 
order of the development of the female organs of genera- 
tion, cannot be mistaken : these organs are in a measure 



MIDWIFERY ILLUSTRATED. 61 

useless for the support of the life of the individual during 
infancy and childhood, and are then remarkable only for 
their extreme smallness : as the cavity of the lower pelvis 
is very much contracted at the moment of birth, and during 
the first ten or twelve years, they are situated principally 
in the abdomen: the external labia scarcely exist; the 
internal labia alone present a development which might 
deceive, if we did not remember that this circumstance is 
common in all females at the moment of birth : the vagina 
is short and very narrow. 

The uterus, which at the birth of the child is situated out 
of the cavity of the pelvis, is found on a level with the last 
lumbar vertebra : its body is not large, and is narrow, thin, 
and elongated : its cavity is extremely small : finally, the 
uterus increases but very slowly, until the period of pu- 
berty ; but at this time it enlarges very much, as do the 
ovaries, and becomes the seat of a very active nutrition : 
its vessels are dilated, it receives a greater quantity of 
blood, and its internal surface assumes a reddish tint, which 
indicates the proximate occurrence of menstruation : finally, 
it assumes its permanent size, and descends entirely into 
the cavity of the pelvis. 

We shall not mention in this place the changes which 
occur in the uterus during gestation : they will be stated 
hereafter, when treating on pregnancy. After the turn of 
life, and in aged females, the uterus becomes smaller ; its 
internal surface gradually loses the reddish tint presented 
by it since the menstrual discharge was established, and it 
becomes white, as before the period of puberty. Finally, 
the neck is more deformed in those females who have borne 
several children, and deep lacerations are often seen in it. 

The appendages of the uterus are developed in the same 



THE FETUS AND ITS APPENDAGES, 



CONSIDERED IN THEIR RELATIONS WITH THE HISTORY OF PREGNANCY, 



AND 



THE PRACTICAL SCIENCE OF OBSTETRICS. 



The history of the fetus includes, 1st, its development ; 
2d, that of its appendages ; 3d, its nutrition and circulation ; 
4th, its general and special division. 



I. DEVELOPMENT OF THE FETUS. 

We see nothing in the uterus previous to the seventh day, 
to indicate the presence of a new being. 

At the eighth day, there is a mucilaginous film, and some 
transparent filaments. 

At the tenth day, a grayish, semi-transparent floccula, 
the form of which cannot be determined. 

From the twelfth to the thirteenth day, there is a vesicle 
as large as a pea, containing a thick fluid, in the midst of 
which swims an opaque point (punctum saliens). It is 
thought that the heart alone exists at this period, and this 
also is the first lineament of the child, which is now termed 
the embryo. It is enveloped by the chorion and the amnios. 
Its weight is estimated at one grain. 



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At the twenty-first day, the embryo appears in the form 
of a large ant (Aristotle), of a grain of wheat {Burton), of 
the malleus (Beaudeloque) : it weighs from three to four 
grains, and is from four to five lines long. At this time, 
the different parts of the fetus are rather more consistent: 
and those parts which afterwards become bones, now pass 
to the state of cartilage. (See PL XVII. Fig. 1.) 

At the thirtieth day, the fetus resembles a worm which is 
compressed and bent upon itself. We observe at this period, 
some very faint traces of the principal organs, and of the 
situation of the upper extremities. It weighs from nine to 
ten grains, and its length is from ten to twelve lines. 

At the forty-fifth day, the form of the child is very distinct, 
and it is now termed the fetus. The clavicles and the 
scapulae, hitherto cartilaginous, now begin to ossify : the 
limbs appear in the form of tubercles, resembling the 
sprouts of vegetables. The body lengthens, but preserves 
its oval figure: the head, which is larger, constitutes one of 
its extremities : the base of the trunk, which is pointed and 
elongated, forms the other. The eyes, mouth, and nose, are 
marked by blackish points and lines. Similar, and parallel 
points, correspond to the place of the vertebrae. Its weight 
is one drachm, its length is two inches. (See PI. XVII 
Fig. 2 and 3.) 

At two months. All the parts of the fetus are present ; 
the dark points which represent the eyes, enlarge ; the eye- 
lids may be traced, and appear very transparent : the nose 
begins to be prominent : the mouth enlarges and opens : 
the brain is soft and pnlpy : the neck shows itself: the 
heart is very much developed, and opaque lines are seen to 
proceed from it, which are the first traces of the large 



66 MIDWIFERY ILLUSTRATED. 

vessels. The fingers and toes are distinct. Its weight is 
five drachms, and its length four inches. 

At ninety days (three months). All the essential parts 
of the fetus are perfectly formed and developed. The eye- 
lids, although enlarged, are exactly closed: a small hole 
shows the place of the external ear : the back and the alee 
of the nose are prominent : the lips are very distinct, and 
are in close contact, and the mouth is shut. The genital 
organs of both sexes also are now very much increased in 
size : the penis is very long, the scrotum empty ; sometimes, 
however, it is filled and distended with a little water. The 
vulva is very apparent, and the clitoris is prominent. The 
brain, although still pulpy, is very much developed, as is 
also the spinal marrow. The heart pulsates strongly, and 
the principal vessels carry red blood. The lungs are empty, 
and hardly visible : the liver is very large, but soft and 
pulpy ; it secretes but little bile. The whole of the upper 
and lower extremities are developed : the long bones of 
these limbs are evidently ossified, as are also the ribs, and 
the flat bones of the skull : finally, the muscular system 
begins to be marked. Weight, two and a half ounces; 
length, six inches. Intellectual functions undeveloped. 
(See PL XVII. Fig. 6.) 

At one hundred and twenty days (four months)* This 
period is remarkable for the great development, and the 
marked character of all the parts of the fetus. The head 
and the liver alone increase no longer, and constantly 
become less and less in proportion to the other parts. The 
brain and the spinal marrow become more consistent : a 
little meconium collects in the commencement of the intes- 
tinal canal : the muscular svstem is distinct, and the fetus 
moves slightly, but almost imperceptibly. We here and 



MIDWIFERY ILLUSTRATED. 67 

there find some cellular tissue. Length, eight inches ; 
weight, from seven to eight ounces. Intellectual functions 
undeveloped. (See PL XVII. Fig. 7.) 

At one hundred and fifty days (five months). The deve- 
lopment of all the parts of the fetus is not only greater, but 
at this period individual differences appear : the muscular 
system is very well marked, and the motions of the child 
are no longer equivocal : the lungs increase, and are capable 
of being dilated to a certain extent. The envelope of skin ) 
although existing for a long time, becomes, especially at 
this period, very consistent : the epidermis is stronger and 
thicker : the meconium is more abundant, and descends in 
the intestinal canal : the places for the nails are marked 
out. Length, ten inches; weight, one pound. Intellectual 
functions, none. (See PL XVII Fig. 8.) 

At one hundred and eighty days (six months). At this 
period, the child may strictly be said to be in a measure 
viable : the nails may be distinguished : a little of down, the 
first indication of the hair, is seen on the head, the thymus 
gland exists, the meconium passes through a great portion 
of the intestinal canal, the testicles appear in the abdomen, 
and begin to move towards the inguinal ring : the cellular 
tissue is abundant, and a little adipose tissue is deposited in 
its cellules : the form of the whole child is distinct. Length, 
twelve inches ; weight, two pounds. Intellectual functions 
undeveloped. 

At two hundred and ten days (seven months). Every 
part of the fetus is enlarged : the child is perfectly viable : 
the nails are formed : the hairs of the head appear : 
the testicles descend into the scrotum. The child, if born 
at this period, can breathe, cry, and suck. The meconium 
descends into the large intestine, and the whole osseous 



68 MIDWIFERY ILLUSTRATED. 

system of the skull, the ribs, and the limbs, is complete: 
the extremities of the long bones alone remain as epiphyses : 
the arterial canal enlarges : the pulmonary arteries, on the 
contrary, remain small. Length, fourteen inches ; weight, 
three pounds. Intellectual functions undeveloped : the 
senses are alone susceptible of some impressions. (See PL 
XVIII. Fig. 1.) 

At two hundred and forty days (eight months). Viability, 
growth of the fetus nearly terminated; each part assuming 
separately its strength and volume : the muscular system is 
very well marked. Length, sixteen inches; weight, four 
pounds. Intellectual functions undeveloped : the senses 
susceptible of impressions. 

At two hundred and seventy days (nine months). The 
common and natural period of the birth of the child : the 
organs have then acquired all that is necessary to support 
life. (See PL XVIII Fig. 2) 

The whole osseous system rapidly gains that degree of 
solidity proper for the functions which devolve upon it. 
The muscular system is very well marked, and the motions 
of the child are lively and quick : the heart pulsates quickly, 
the circulation is very active, the blood is abundant and 
rich in nutritious principles, the nervous system is very 
apparent : the lungs perform their functions, and respiration 
is established : great changes take place in the manner of 
the circulation : the whole alimentary canal, which hitherto 
had no special action, can immediately become active : the 
intestinal canal contracts upon the meconium, which tends 
to escape through the anus : the urine is excreted, the arte- 
rial capillaries of the skin become very active, the skin is 
colored, and transpiration is established. Length, eighteen 
to twenty inches ; weight, five to six pounds. Intellectual 



MIDWIFERY ILLUSTRATED. 69 

functions are undeveloped, but the senses (particularly the 
taste) are very much so. The child is sensible to pain, it 
cries from hunger and cold, it is appeased by warmth and 
nursing, and gentle rocking puts it to sleep. 



II. DEVELOPMENT OP THE APPENDAGES OF THE FETUS. 

The term secundines or appendages of the fetus, includes 
the several membranes which envelope it, the fluids they 
contain, the placenta, and the umbilical cord. 

The fetus has three envelopes : the most external, is the 
epichorion; the middle, the chorion; and the internal, the 
amnios. 

The epichorion appears when the uterus is first impreg- 
nated, and is seen in this organ even when pregnancy of the 
Fallopian tubes exists. This membrane is formed by the 
concrete lymph poured out by the exhalants of the uterus 
after impregnation, and appears in the form of a coagulated, 
whitish, albuminous, and very soft layer. Until about the 
second month of pregnancy, the epichorion is formed of a 
single layer : it may afterwards be divided into two distinct 
folds, the internal of which is the reflected caducal mem- 
brane of Hunter. At the end of pregnancy, the epichorion 
is separated from the uterus and remains entirely adherent 
to the external face of the chorion, from which it may 
easily be detached at parturition. 

The chorion is the first and the most external membrane 
of the fetus. Its external face looks toward the epichorion 
its internal face to the amnios. It is thicker in the early 
stages of pregnancy, but becomes thinner as the period of 
parturition approaches. Between the second and third 



70 MIDWIFERY ILLUSTRATED. 

month of gestation, these vascular, whitish flocculoe are 
developed upon a part of its uterine surface, which are 
designed to form the placenta which Haller considers only 
an indurated portion of the chorion. 

The chorion serves to unite the ovum with the uterus, 
contributes to form the placenta, sustains the amnios, and 
transmits to this membrane the minute and colorless ves- 
sels which pour into its cavity the liquid which supports 
the fetus. 

The amnios is the second, or rather the proper membrane 
of the fetus, which it covers and supports : it supplies and 
holds the waters in which the fetus is situated. The am- 
nios is transparent, diaphanous, and a little thicker than the 
chorion. Its external face corresponds to this latter mem- 
brane, to which it adheres slightly, by means of a great 
number of minute colorless vessels, which are easily rup- 
tured after parturition. Its internal face looks toward the 
fetus, and is in direct contact with the waters. (See PL 
XVII. Fig. 8.) 

The uses of the amnios are to contain the ovum, and to 
secrete the waters in which it is situated. The chorion and 
the amnios, beside their special uses, serve also to sustain 
the weight of the waters during labor, and thus to facilitate 
the dilatation of the neck of the uterus. 

The history of the membranes is naturally followed by 
that of the waters they contain. These are termed the 
waters of the amnios, or the amniotic fluid. These waters 
are generally clear, limpid, diaphanous, tasteless, and 
colorless : sometimes, however, they are turbid, muddy, 
often grayish, brownish, and extremely fetid towards the 
end of pregnancy, though the fetus exhibits no manifest 
alteration. 



MIDWIFERY ILLUSTRATED. 71 

The waters, compared with the size of the sac which con- 
tains them, are more abundant at the commencement than 
at the end of pregnancy. 

The most general opinion in regard to their formation 
and nature is, that they come from the mother, and are sup- 
plied by the exhalants of the uterus, which transmits them 
through the anastomoses of the placenta to the capillary 
vessels of the chorion, whence they pass through the pores 
of the amnios, and nitrate, like fine dew, into the cavity of 
this membrane. 

The waters have several important uses. They serve to 
sustain the fetus and to preserve it from the fatiguing 
efforts of the mother ; at a later period they facilitate the 
dilatation of the uterus, and especially that of the neck, at 
the moment of parturition. 



PLACENTA. 



In the latter periods of pregnancy, the placenta is a 
spongy, cellular, vascular mass, most commonly circular 
and flattened, an inch thick in the centre, thinner on the 
circumference, and from seven to eight inches broad : its 
weight, together with its membranes and the umbilical cord, 
is generally twelve ounces. 

It presents an external, uterine, convex, lobular face, 
which intimately adheres to the uterus during the whole of 
pregnancy: the opposite face, the internal, fetal or umbilical, 
presents numerous divisions of the umbilical vessels. It is 
directly covered by the chorion. 

The placenta is attached most commonly to the posterior 
or superior face of the uterus. Sometimes, however, we 



72 MIDWIFERY ILLUSTRATED. 

find it on its sides; sometimes, also, but more rarely, 
toward the orifice, and even directly over the os tincoe. 

The umbilical cord is generally inserted near the centre 
of the placenta ; when the attachment occurs in any part 
of its circumference, the placenta is termed en raquette. 
The placenta is formed of several lobes or cotyledons; 
these are easily distinguished on its uterine surface, but are 
united in one mass on its fetal face. 

The parenchyma of this organ is easily torn : its color is 
dark red. It is composed of blood vessels, cellular 
tissue, and whitish, dense, resisting filaments ; the latter are 
more numerous and more apparent at the end of pregnancy, 
and seem to be only the obliterated branches of the vessels. 
(See PL XIX. Fig. 1 and 2.) 

Every fetus has a placenta : in a twin pregnancy, how- 
ever, the two placentas are sometimes united at their edges, 
but the circulation for each child is distinct, although anas- 
tomoses between their vessels may be demonstrated. (See 
PL XX. Fig. 1.) 



UMBILICAL CORD. 

The umbilical cord is a vascular fasciculus, which 
extends from the placenta to the umbilicus of the child. It 
is very short at the beginning of pregnancy, and is formed 
at this time by the omphalo-mesenteric vessels, by the um- 
bilical arteries and veins, and by these latter alone at the 
end of pregnancy. Its length is commonly from eighteen to 
twenty-four inches ; but not un frequently it is much longer 
or much shorter : in the latter case, knots may be formed in 
one or more parts of its extent. 



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MIDWIFERY ILLUSTRATED. 73 

All cords are not similar : we distinguish those which are 
large, thin, short, varicose, or knotty: the large are not 
generally the firmest; and we can depend most upon the 
thin cords when it is necessary to pull upon them in 
order to deliver the placenta. (See PL XX Fig. 2.) 



NUTRITION AND CIRCULATION OF THE FETUS. 

Nutrition. It is an incontestable fact, that the fetus is 
nourished by the fluids derived from the mother ; but it is 
not equally easy to demonstrate by what mode and in what 
manner these fluids come to it. Physicians differ much 
upon this great physiological question. In fact, some 
assert, that the infant is nourished by sucking the waters 
in which it is inclosed, and that these fluids, on entering 
the stomach, are subjected to the common laws of digestion, 
and thus become the elements of the nutrition of the fetus. 
But experiments made on the waters of the amnios have 
demonstrated, that they contain but little, or rather no 
nutritious substance : that at the end of pregnancy particu- 
larly, they are often turbid, blackish, purulent, &c. : it has 
also been observed, that the membranes are sometimes rup- 
tured for several days, a month even before the commence- 
ment of real labor, which would necessarily cause the 
premature discharge of the waters of the amnios, long before 
that of the child : finally, it is certain that some children 
have been born with the mouth imperforate, and conse- 
quently it was physically impossible for them to receive 
any of the amniotic fluid. 

The reasons adduced in support of the opinion we have 
mentioned, also deserve to be answered. It is asserted, 



74 MIDWIFERY ILLUSTRATED. 

that the child, by sucking the waters of the amnios, pre- 
pares for the more complex and more difficult operation of 
sucking the mother. We must admit, that this propensity 
of the new born child, and the power of exercising it at 
birth, are phenomena as astonishing as they are inexpli- 
cable; but how is it that the young duck, when hatched 
out by a hen, as soon as it emerges from the shell, plunges 
into the water, regardless of the cries of its mother, while 
the chicken of the same brood avoids this element? Besides, 
there is nothing on the inside of the amnios resembling the 
nipple, which might be sucked by the fetus, and therefore 
its propensity at the moment of birth is innate, and not an 
acquired faculty. 

On the other hand, the opinion which tends to demon- 
strate that the fetus is nourished by intussusception, or by 
absorption, cannot be admitted. The cutaneous system of 
the fetus is inactive as long as it continues in the uterus, 
and the waters have neither the properties nor the qualities 
proper for absorption. 

Those physiologists who have attempted to explain the 
nutrition of the fetus, may have erred by confounding this 
nutrition with proper digestion, wishing to establish an 
analogy between this imaginary digestion of the fetus and 
that of the adult ; they have maintained that the nutritious 
juices should follow the same course, and pass through the 
same passages in both ; not thinking that one lives in a light, 
elastic, seriform fluid, that it enjoys fully an active respi- 
ration, and all the advantages of a rich and abundant circu- 
lation, while the other rests in the midst of the uterus, 
surrounded by a thick and incompressible liquid, has no 
respiration, and only as it were a vegetative life, and 
an imperfect existence. All these reasons, and as many 



MIDWIFERY ILLUSTRATED. 75 

more, which are superfluous, should lead us to reject both 
the theory of deglutition, and that of absorption, as the 
only modes in which the fetus is nourished. The fetus, 
then, must be considered during the whole of pregnancy, as 
a new part, added for a time to the female, which part is 
nourished through the common and known medium of the 
circulation. The child then receives the fluids necessary 
for its growth through the umbilical cord, and does not 
subsist upon the waters of the amnios. 

Circulation of the fetus. If the circulation in the fetus 
were the same as in the adult, we should omit it; but 
it differs in several respects, and therefore requires a 
particular description. 

As the fetus has no organs to perform the hematosis, 
since the lungs are inactive till the moment of birth, it is 
necessary for the mother to furnish, already prepared, the 
fluids which, as soon even as they are carried into the 
circulation, become the elements of its nutrition. This 
function belongs to the umbilical vein. 

This vein arises in the placenta, goes toward the umbi- 
licus of the child, and, without communicating with the 
umbilical arteries, penetrates into the abdomen. Being 
sustained by a fold of the peritoneum, it is directed from 
before backward, and from below upward, toward the 
upper part of the great fissure of the liver. There it gives 
off a large and short twig, a kind of sinus destined for the 
liver, into which it penetrates after dividing into two 
branches, one for the right lobe, the other for the left. 
(See PL XXI. Fig. 2.) 

The umbilical vein then becomes very small, and goes 
under the name of the venous canal towards the right 



76 MIDWIFERY ILLUSTRATED. 

auricle of the heart, into which it penetrates, blended with 
the ascending vena-cava. The blood which comes to the 
heart through this latter, is separated by the Eustachian 
valve from the current formed by the descending vena-cava. 
Being sent forth in a different direction, it strikes against 
the septum of the auricles, passes through the foramen 
ovale or the foramen of Botal, and raises its valve, which 
being on the side of the left auricle, does not permit the 
blood to repass into the right auricle. 

Arrived in the left auricle, the blood is transmitted into 
the left ventricle, and from thence into the ascending aorta, 
at least in great part : after passing through the head and 
the thoracic extremities, it is carried by the descending 
vena-cava into the right auricle, which sends it into the 
right ventricle, and from thence it passes into the trunk 
of the pulmonary artery. A small portion of the blood 
which is transmitted through this artery, goes to the 
lungs, which being collapsed and inactive, cannot receive 
more of it. Most of it passes into the descending aorta, by 
the arterial canal, (See PL XXI Fig. 2), and after pro- 
ceeding through the whole extent of this latter, returns to 
the mother through the umbilical arteries. (See PL XXI. 
Fig. 4.) 

The following are the most remarkable changes in the 
circulation of the fetus at the moment of birth. 

As soon as the air enters the lungs of the new born child, 
and respiration is established, the blood which is then 
brought into relation with the vesicles of air, immediately 
experiences the most remarkable changes, and instead of 
black, suddenly becomes red and very light. This blood 
returns for the first time through the pulmonary veins into 



MIDWIFERY ILLUSTRATED. 77 

the left auricle, depresses the valve of the foramen ovale, and 
thus opposes the transmission of that which, during the 
whole of pregnancy, arrived through the right auricle: 
carried into the left ventricle, and thence into the aorta, it 
passes through the whole extent of this vessel, and effaces 
the communication between this latter and the pulmonary- 
artery, by means of the arterial canal which collapses and 
is finally obliterated. The column of blood which passes 
through the lower part of the aorta, when arrived at its 
place of bifurcation, no longer passes through the umbilical 
arteries, but is sent into the iliacs and thus goes abundantly 
into the lower extremities. 

In consequence of the depression of the valve of the 
foramen of Botal, the blood which returns from the lower 
parts, being carried into the right auricle through the 
ascending vena-cava, mixes for the first time with that 
which comes from the upper extremities, returned into the 
same by the descending vena-cava. The blood, when trans- 
mitted from the right auricle into the ventricle of the same 
side, is sent into the lungs through the pulmonary artery, 
and the arterial canal is gradually obliterated. 

We terminate the anatomical and physiological history 
of the fetus by a word upon its length, weight, situation, 
and motions. 

The length of a full-grown child is generally from 
eighteen to twenty-one inches ; its weight varies more, and 
is from five to seven pounds. When less than five pounds, 
the child is delicate, feeble, or sick, and cannot always be 
expected to live; when its weight is more than seven 
pounds, and eight, nine, or even ten pounds, it is unusually 
large: its delivery is generally laborious, and sometimes 



78 MIDWIFERY ILLUSTRATED. 

even impossible by natural means, and often requires the 
assistance of art. 

The position of the fetus in the mother is absolute or 
relative. The absolute position results from the special 
manner in which the different parts of the infant are 
arranged when compared with itself: in most cases, it is 
bent upon itself, the head being flexed on the chest, the 
arms crossed and supported on the thorax, the thighs bent 
upon the abdomen, the legs on the thighs, and the heels on 
a level with the thighs. In this bent up position, it repre- 
sents an oval figure, the greatest diameter of which, from 
the occiput to the heels, is from nine to ten inches. 

The relative position of the fetus is only its peculiar 
situation in the uterus, at different periods of pregnancy. 
The ancients had very singular ideas on this subject: they 
asserted, that during the first seven months of pregnancy, 
the fetus rested on the vertebral column, the head upward, 
the thighs downward, and that at the seventh month, it 
made what they termed a somerset. This old error is no 
longer tenable. In fact, touching demonstrates, that in 
most pregnant females, the child's head rests near the neck 
of the uterus, long before the seventh month, and that it is 
found there even at the fifth. (For the situation of the 
fetus, see PL XVII. and XVIII) This situation, however, 
varies in several ways, as is proved by those labors in 
which the fetus presents successively the feet, the thighs, or 
some other part, the presence of which being an insur- 
mountable obstacle to the natural termination of the labor, 
requires the employment of more or less laborious means 
to obtain it. This will be mentioned hereafter, when 
describing the manoeuvre. 

The motions of the fetus are spontaneous or active, com- 



MIDWIFERY ILLUSTRATED. 79 

municated or passive. The active motions depend on the 
action of its muscles, and are manifested as soon as this 
action can be brought into play. Usually, they begin to be 
felt about the middle of the fourth month of pregnancy, and 
are at first very feeble : they then increase, and sometimes 
become so active and quick, as to incommode the mother 
very much. These active motions prove to her that the 
child is living. 

The passive or communicated motions are those which 
may be caused by different positions of the female. By 
touching, certain special motions are impressed on it, which 
are termed ballottement, and which may strictly be made 
perceptible from the fifth month, and even sooner, as expe- 
rience shows daily. These motions prove to the accoucheur 
that the child is present in the developed uterus, and are 
the pathognomonic sign of pregnancy. 

The results obtained by the stethoscope only confirm the 
first proofs : but these alone are insufficient. 



DIVISION OF THE FETUS. 

After studying the fetus in its anatomical and physiolo- 
gical relations, we proceed to consider it in the practice of 
obstetrics. 

If parturition terminated always in the same manner, if 
it were never attended with accidents, if on the contrary, 
the assistance of art was not often necessary, the details 
about to be given, would be perfectly useless. Unfortu- 
nately, experience proves, that the life of the female and 
her child would frequently be compromised, if powerless 
nature were unassisted. 



80 MIDWIFERY ILLUSTRATED. 

The fetus may be divided into the head, the trunk, and 
the extremities, or lower limbs ; the upper limbs belonging 
to the trunk in our division. 

The head is oval, elongated from before backward, and 
is composed of the skull and face. The skull is much 
larger proportionally than the fare; it is formed of the 
same bones as in the adult, with this difference, however, 
that the frontal bone is always divided into two equal parts, 
a right and a left. 

In the fetus, the bones of the skull are very movable, and 
the head is easily compressed longitudinally. These advan- 
tages are owing to membranous sutures, which unite the 
bones of the skull, and to several fontanelles, which are also 
membranous: two, particularly, are remarkable for their 
extent ; one, the anterior, the frontoparietal, is quadrila- 
teral : it is situated in the centre of the sincipital region : 
the other, the posterior, the occipitoparietal, is trian- 
gular, and occupies the centre of the occiput. {See PL 
XXIII. Fig. 1.) 

In the head of the fetus, we distinguish four diameters, 
and four circumferences. 

The first diameter, the occipito-mental, extends from the 
centre of the lower jaw to the occiput; it measures five 
inches. (See PL XXIII Fig. 3.) 

The second, the occipitofrontal, extends from the centre 
of the forehead to the occiput ; it measures four and a half 
inches. (See PL XXIII. Fig. 3.) 

The third, the bi-parietal, extends from one parietal pro- 
tuberance to the other ; it measures three and a half inches. 
(See PL XXIII Fig. 1.) 

The fourth, the basio-sincipital, extends from the centre 
of the anterior fontanelle, perpendicularly to the base of the 



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MIDWIFERY ILLUSTRATED. 81 

skull : it measures three and a half inches. (See PL XXIII. 
Fig. 3.) 

The great circumference passes around the head of the 
fetus from the forehead to the occiput, and thence returns 
over the base of the skull to the same point : it measures 
fifteen inches. (See PL XXIV. Fig. 1.) 

The middle circumference proceeds over the head from 
the forehead to one of the parietal protuberances, thence to 
the occiput, and returns to the forehead, passing over the 
parietal protuberance of the opposite side : it measures 
thirteen and a half inches. (See PL XXIV. Fig. 2.) 

The small circumference leaves the sinciput, passes on 
one of the parietal protuberances, and returns to the point 
whence it started, proceeding over the base of the skull and 
the parietal protuberance of the opposite side : it measures 
eleven and a half inches. (See PL XXIV Fig. 3.) 

The head can move in several directions, the knowledge 
of which is useful. The motion of flexion on the chest, and 
inclination on the shoulders, are safe. The motion of 
flexion backward, or rather of extension, when carried too 
far, may cause serious accidents, and even the death of the 
child. 

The motion of rotation can only extend to one eighth of 
a circle : carried farther, it will inevitably cause the death 
of the child. 

A knowledge of the trunk is much less important than 
that of the head : we shall only state, that the diameter 
between the shoulders, the acromial diameter, is four 
inches ; and that its motions, which are less extensive than 
those of the head, must be made in the natural direction, 
especially in the different cases where any manoeuvre is 
required. 

10 



82 MIDWIFERY ILLUSTRATED. 

The limbs of the fetus are very flexible. In fact they are 
like cotton, when bent in their natural direction; but of iron, 
when we attempt to curve them in the opposite. 



NATURAL HISTORY OP PREGNANCY. 

In the history of pregnancy, we must consider, first, its 
definition : second, its different divisions : third, its signs. 

It must be admitted, that pregnancy forms the most 
important part of the generative functions; but it alone 
does not compose their whole history. In fact, the fulfill- 
ment of these functions requires the concurrence of several 
phenomena, which are all directed towards the same end, 
and all have for a definite result, the birth of a new being. 

Menstruation is the prelude to the great work of repro- 
duction, which cannot be accomplished without a prelimi- 
nary and indispensable act, which is repeated with infinite 
shades, in all species possessing the power of reproduction : 
this act is generation. Conception then, is only the union 
of the principles supplied in the act of generation, and 
pregnancy the positive state of a female who has conceived. 
But how long a period elapses between each of these two 
great phenomena? Anatomy cannot tell: physiology, with 
her brilliant hypotheses, cannot inform us : the imagination 
alone can scarcely appreciate the imperceptible distance 
between them. The only mode of making known her ideas 
on so wonderful a subject is to say : From the moment that 
generation takes place, conception occurs, and pregnancy 
exists. 

Definition. From these remarks, pregnancy may be 
defined : the state of a female, who, after conception, con- 



MIDWIFERY ILLUSTRATED. 83 

tains within her the fecund principle of a new being. 
Pregnancy commences, then, directly after conception, and 
terminates by parturition. Its entire duration is usually 
two hundred and seventy days, or nine solar months. 
However, this period may possibly be retarded or advanced 
some days, as is proved by well supported facts. But this 
is not the place to examine a subject which belongs to 
legal medicine. 

Division and differences. Pregnancy must be considered, 
first, according to its situation ; second, the nature of 
the substances which form it; third, the number of the 
productions which compose it. 

In regard to its situation, it is divided into uterine and 
extra-uterine : each may be true or false. 

A. Let us first mention extra-uterine pregnancy. We 
distinguish three principal kinds, viz: pregnancy in the 
Fallopian tube, ovarian pregnancy, and abdominal preg- 
nancy, which may be primitive or secondary. Several 
other varieties of extra-uterine pregnancy may be admitted. 
These will not be mentioned by us, as the most eminent 
practitioner scarcely sees an instance of their occurrence. 

In extra-uterine pregnancies, the product of conception 
rarely reaches its fall growth : admitting even that it does, 
as the female cannot expel it from the place in which it is 
situated, its death is an inevitable consequence of nature's 
error. 

The signs of extra-uterine pregnancy are very equivocal : 
consequently, it must be recognized, not by analogy, but 
rather by opposition to uterine pregnancy. 

As the issue of all these pregnancies is most generally 
unfortunate, when the child arrives at a certain size, the 
happiest termination for the female is the death of the fetus 



84 MIDWIFERY ILLUSTRATED. 

about the second or third month of pregnancy ; its deve- 
lopment thus being arrested, it putrifies. 

B. Uterine pregnancy is that in which the product of 
conception, being deposited in the uterus, is there developed 
according to the known laws of the organization of animals. 
It is divided into true or false. 

The term false or apparent pregnancy, is generally 
applied to any state of the female which resembles real 
pregnancy, and may deceive even the most experienced 
physicians. 

The different circumstances which may give rise to 
these kinds of pregnancies, generally depend on more or 
less severe morbid affections which may affect the uterus 
or its appendages, the intestines, or any other part of the 
abdomen : among these we must mention particularly, 
moles, hydatids, polypi, water, blood, mucus, air, chronic 
induration of the uterus, the development of a fibrous 
body in its substance, schirrus, dropsy of the ovaries, of the 
tubes, ascites, tympanitis, tumors in the mesentery, &c. &c. 

True uterine pregnancy is also called natural, common, 
favorable, &c. ; it may be simple or compound. It is simple 
when there is but one fetus in the uterus ; compound, when 
there are several. 

Signs. The signs of pregnancy may be distinguished 
into presumptive or rational, and positive or sensible. 

A. The presumptive or rational signs are those which 
induce us to suspect or presume that the female is preg- 
nant. Although these signs are quite numerous, they are 
very uncertain, and we can only draw conjectures from 
their existence. Some of these signs affect the whole 
system ; these are the general presumptive signs : others 
merely manifest themselves in some special point of the 



MIDWIFERY ILLUSTRATED. 85 

economy ; these are the particular or local signs. The first are 
drawn from all the changes experienced by the female in the 
regular and natural progress of her functions, in her habits, 
her peculiar inclinations and tastes, the effects of which are 
marked particularly by the paleness of the countenance, and 
a certain alteration in the figure, which belongs only to 
pregnant females, but which the most experienced eye 
cannot always detect. 

The particular or local signs are more positive : we may 
prove their existence : when alone, they do not indicate 
with certainty the reality of pregnancy, but they deserve 
all the attention of the practitioner. These signs are first, 
the suppression of the menses ; second, the enlargement and 
development of the abdomen ; third, the discoloration of 
the areola, its brownish appearance; fourth, the swelling 
of the mammae, and the dribbling from the nipple. 

1. There are two remarkable periods in the life of the 
female, during which the menses are suppressed, although 
the health is not manifestly incommoded : these two periods 
are during pregnancy and lactation. The suppression of 
the menses, however, is so far from being a certain sign of 
pregnancy, that it is not always a rational sign ; this evacua- 
tion is more subject than any other to variation and derange- 
ment. Besides, its constant and regular appearance does 
not prove that the female is not pregnant, since numerous 
examples show that females, although pregnant, have men- 
struated, at least during the early months of gestation. 

2. When a female perceives that her belly enlarges, and 
is developed, she believes herself pregnant, especially if this 
sign be complicated with the suppression of the menses. 

It is true that pregnancy is attended with an enlargement 
and development of the belly : but the causes, independent 



86 MIDWIFERY ILLUSTRATED. 

of pregnancy, which may produce this development, are 
too numerous for us to attribute to this sign its true value 
in case of real pregnancy. Farther, the belly does not 
visibly enlarge until after the third month, and as touching 
at this early period of pregnancy, can afford but vague 
conjectures, we must pronounce, very reservedly, upon 
an increase in the size of the belly as a rational sign of 
pregnancy. At a later period, when pregnancy is very 
much advanced, the size of the belly does not confirm it: 
other and more positive signs leave no doubt of its presence. 

3. The sympathy between the uterus and the mammae 
explains sufficiently the influence of pregnancy on the 
latter. This influence is not felt, generally, until towards 
the fourth month ; but it does not cease until after parturi- 
tion, at which time other functions are established in these 
organs. Not unfrequently, however, the mammae swell, at 
the early periods of pregnancy, and there is even a manifest 
dribbling from the nipples. These anomalies render the 
swelling of the mammae uncertain as a presumptive sign of 
pregnancy, although it is one of the least equivocal, because 
the causes which occasion false pregnancies, rarely pro- 
duce on the mammae the same effect as real pregnancy. 
Alone, however, the swelling of the mammae and the 
dribbling from the nipple, should be far from inducing the 
belief of pregnancy, since these phenomena have appeared 
in females who were not pregnant, and even in very young 
girls. 

4. The dark and brownish color of the areola and the 
nipple, is generally regarded as a sign of pregnancy, because 
it is demonstrated that dropsies, and all other circumstances 
which may produce an enlargement of the belly, have no 
action on the mammae, and do not change the form or color 



MIDWIFERY ILLUSTRATED. 87 

of these organs. This sign, however, would not always be 
sufficient to confirm the existence of pregnancy; some 
females naturally have a dark areola, and others, who have 
even borne several children, have never experienced any 
alteration in this part, which has always preserved a 
slightly rosy color, even after several pregnancies. 

B. The sensible, positive, or demonstrative signs of preg- 
nancy, are of two kinds. The first are drawn from the 
sight and touch ; they form its experimental or practical 
history. They make known the changes in the form, figure, 
and situation of the uterus, during pregnancy : these may 
be called the physical signs of pregnancy. 

The second are imperceptible to the senses : they result 
from the changes in the organization of the uterus during 
pregnancy, which are produced in it by the properties it 
then enjoys, and which form the physiological phenomena 
of pregnancy. Their study composes what we call the 
physiological history or the rationale of pregnancy : they 
are the true rational signs. 

I. Experimental history of pregnancy. At the end of the 
first month, the accoucheur has no sensible evidence of the 
existence of pregnancy, nor even of a fullness or action in 
the uterus : none of the natural signs are yet manifested, 
and the general signs mentioned by some authors are too 
vague to be believed. This is not true, however, at the end 
of the second month (sixty days) : the practice of touching, 
may strictly teach us to distinguish the state of fullness of 
the uterus, as also the slight changes supervening in its 
figure and size, and lead us to presume the existence of 
pregnancy. The following is a rapid figure of the physical 
phenomena presented during the course of gestation, 
observed at the end of each month. 



88 MIDWIFERY ILLUSTRATED. 

During the first month, the uterus seems to experience 
no sensible change in its form and volume. It is even pro- 
bable that so far from enlarging, it on the contrary contracts, 
as if it would embrace more intimately the new product 
enclosed within it. 

At the end of the second month, it enlarges very much ; 
its form is rounded ; it fills most of the lower pelvis : but 
the belly, on the contrary, becomes more contracted, more 
tense, and sometimes even a little painful. 

After the third month, it increases in size and in length ; 
its base rises as high as the pubic region ; it is then on a 
level with the superior or abdominal strait. The finger, 
introduced into the vagina, perceives its rounded, globular, 
equal form. It may be raised without pain to the female. 
The belly is slightly tumefied by the crowding back of the 
intestine. {PL XXV. Fig. 2.) But the neck is not changed 
in any manner, and consequently can present no evident 
marks of pregnancy. If it were possible to apply the stetho- 
scope within the vagina, its use, at this time, might be valu- 
able by determining the uterus to be filled by an organized 
body. 

At the end of the fourth month, the uterus rises above the 
lower pelvis; its base is two or three fingers' breadth above 
the region of the pubis. The belly is evidently enlarged ; 
but the existence of pregnancy can be best ascertained per 
vaginam. In fact, ballottement is possible at this period, as 
the head of the fetus at this time is large and heavy enough 
to respond sensibly to the motion imparted to it. Even at 
this period, the female sometimes feels the first motions of 
the child. 

At the end of the fifth month, the existence of pregnancy 
may be ascertained with certainty. Both the sensible and 



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MIDWIFERY ILLUSTRATED. 89 

rational signs unite to confirm it. The base of the uterus 
is found at two fingers' breadths below the umbilicus. 
Touching, evidently shows the presence of the child, and 
ballottement, when skillfully performed, manifests it with 
the utmost facility. 

At the end of the sixth month, the uterus is developed so 
rapidly that its base rises two fingers' breadths above the 
umbilicus. Its general form is that of an ellipse very much 
elongated from above downward. By touching, the head of 
the child can easily be felt through its distended parietes. 
Ballottement is performed without difficulty : but at the 
end of the sixth month, one peculiarity exists not observed 
before. The neck of the uterus, which as yet had not par- 
ticipated in the development of its body and fundus, begins to 
enlarge a little towards its base : its lower orifice slightly 
opens, and even the neck swells and becomes softer ; in- 
dicating that it is finally prepared to take part in the general 
dilatation of the uterus. 

During the seventh month, the base of the uterus, which 
has risen a little higher, begins to enter the epigastric re- 
gion. But the degree of its elevation is less, and it decreases, 
and the uterus, instead of being elliptical, tends more and 
more to assume the spherical form, which depends on the 
opening of the neck, and the active part it then takes in the 
dilatation of the womb. In fact, the neck becomes shorter 
and softer. Its lower extremity opens very sensibly, and 
admits the end of the finger with ease. At this time, also, 
the lower planes of the uterus increase in extent, by 
which the woman becomes much larger. Ballottement 
begins to lose its elasticity, the child's head being so large 

that it is no longer displaced with the same facility. But 
11 



90 MIDWIFERY ILLUSTRATED. 

this circumstance only renders pregnancy still more evident, 
and serves to determine its advanced stage. 

During the whole of the eighth month, and especially 
towards the end of it, the base of the uterus occupies most 
of the epigastric region. It becomes much more capacious, 
and more and more spherical and rounded : the umbilicus 
is distended ; the neck becomes shorter, and less hard ; 
it is soft, and enlarged, especially towards its anterior 
lip. The child's head is large and heavy, the finger 
raises it with difficulty, and ballottement can no longer 
be performed. 

At the end of the ninth month, and consequently of preg- 
nancy, the base of the uterus, so far from rising more and 
more, as one might think, is situated lower than it was at 
the end of the eighth month. It is found near the umbilical 
region. The amplitude of the organ affects the sides in 
consequence of the dilatation of the neck and its extreme 
enlargement. The neck itself has entirely disappeared, 
and now assumes the form of a soft cushion, more or 
less enlarged. The child's head becoming larger and 
heavier, is as it were engaged in the superior strait, and it 
is raised with great difficulty. (See PL XXV and XXVI. 
Fig. 4. and particularly PI. XXVII. and XXVIII.) 

Such is a brief statement of the changes in the form, 
figure and size of the uterus during pregnancy ; let us now 
mention those in its organization. They constitute the 
physiological phenomena of pregnancy, with which the 
general history of this function terminates. We shall 
complete this part by the history of touching. 

Physiological phenomena of pregnancy. Beside the 
visible and sensible signs of pregnancy already mentioned, 
there are others which are imperceptible to our senses, and 



MIDWIFERY ILLUSTRATED. 91 

which occur in the proper organization of the uterus : we 
refer to the properties developed by fecundation, and made 
known to us by pregnancy alone. These properties are the 
dilatation of the uterus, its proper action, and its contraction. 

Dilatation of the uterus. This is as remarkable as any 
of the phenomena of pregnancy ; the dilatation in fact is 
slow, but constant and progressive, until parturition. 
Although this dilatation is very evident, it is as surprising 
as it is difficult to explain. In fact it is hard to imagine 
that an extremely small ovum, composed of very thin 
membranes containing a small embryo resembling mucus, 
can, without destroying its frail tissue, extend and dilate an 
organ like the uterus, which is more than half an inch 
thick in every part, and the resistance of which would be 
almost insurmountable, if its dilatation depended solely on 
a mechanical cause. 

However difficult it may be to conceive of the dilatation 
of a body as strong as the uterus, by a substance as weak 
as the fetus, we can easily be satisfied of its possibility, by 
stating the means which industrious nature, attentive to 
the preservation of the product of conception, employs to 
execute it. 

As soon as the fecundated ovum arrives in the uterus, it 
is attached to some point of its internal surface. By the 
extreme irritation there produced, it causes the afflux of 
fluids of every kind, ubi irritatio, ibi humor : the fluids 
passing through the slight tissue which unites the ovum to 
the uterus, are propelled downward with a force proportional 
to the base and the height of the current of all the fluids of 
the system, and must finally force the tissue of the uterus 
to yield, to enlarge from within outward, and consequently 
to dilate. 



93 MIDWIFERY ILLUSTRATED. 

The uterus, however, is by no means inactive in this 
admirable work, nor does it merely yield to the efforts of 
the embryo. The generative act not only communicates 
life to the fecundated germ, but it also affects the uterus, 
which instantly acquires, proprio motu, the power of ex- 
tending, enlarging, and finally of presenting all the pheno- 
mena of dilatation ; and it is to this development, as well 
as to the powerful activity of its vital properties, that the 
uterus owes the varied phenomena of this dilatation, since 
no mechanical agent is necessary to produce it, as the uterus 
dilates in an extra-uterine pregnancy. We must admit, 
however, that the slow but progressive growth of the fetus, 
and the constantly increasing accumulation of the waters 
of the amnios, are powerful causes of this phenomenon, 
which requires the concurrence of these latter to continue 
at the same degree of activity until the end of pregnancy. 
To render this truth still more sensible, we add, that the 
fluid constantly reacts against the parietes of the uterus in 
every direction. Finally, the last cause which tends to 
dilate the uterus, is the development of its vessels, which 
enlarge, and admit a greater quantity of blood ; their 
parietes are thus distended, the uterus is enlarged, and 
consequently is expanded. 

Proper action of the uterus, or of its tone. The uterus, so 
far from being passive during pregnancy, possesses an active 
power, proportional to the force and energy of its vital 
properties. This power, which the ancients termed the 
tonic force, and to which the moderns have applied the 
expression organic contractility, or the contractility of 
the tissue, is so inherent in the special organization of 
the uterus, that when lost during gestation, both the 
mother and child are affected with symptoms which are 



MIDWIFERY ILLUSTRATED. 93 

much more serious, because their formidable consequences 
cannot always be subdued. This, however, might be at- 
tained, if we were better acquainted with the manner in 
which this property acts, the principal end of which is the 
certainty and preservation of pregnancy. 

But although it may be very difficult to determine the 
true character of the tone of the uterus, it is very easy to 
point out the bad effects resulting from its opposite state, 
which is termed uterine inertia, or syncope ; in this state, 
the feebleness of the uterus depriving it of sensation and mo- 
tion, it is incapable of contracting, and the orifices of a great 
number of blood-vessels are naked and open, the hemorrhage 
from which may destroy the mother and child. One evident 
proof that the inertia of the uterus alone causes the symp- 
toms, is, that the true remedy is to excite the tone of the 
uterus, by rubbing the abdomen, by applying cold water 
and vinegar to the same region, and also to the internal and 
upper part of the thighs ; finally, by all the modes which 
are proper to cause its contraction and tend to restore its 
primitive degree of energy. 

Contractility of the uterus. Besides the two properties 
already mentioned, the uterus possesses another power also, 
in common with all the voluntary muscles, viz. : contracti- 
lity. It differs from them, however, in several respects, 
which it may be useful to mention. Generally, the uterus 
never contracts so forcibly as when it wishes to expel some 
material body, which is inclosed in its cavity, which is 
more or less enlarged, whatever may be the cause producing 
it : so far from being entirely voluntary, the contractility 
of the uterus seems involuntary. In fact, during the early 
stages of labor, there are frequently long intervals between 
the pains, and the female cannot accelerate their return at 



94 MIDWIFERY ILLUSTRATED. 

pleasure, however impatient to be speedily delivered. On 
the other hand, in the last stages of labor, the pains are so 
severe and return so quickly that the female is not only 
unable to arrest them, even if she wishes it ; but she is even 
obliged to second these efforts, and to assist in expelling the 
child's head, and consequently in terminating the labor. 

The contractility of the uterus resides essentially in the 
tissue of this organ, as does likewise the painful sensation 
attending it ; hence, the term pains is commonly applied to 
the contraction itself. The last character of this faculty is, 
that its force and energy are always proportional to the 
obstacles opposing it, and the efforts made to conquer it. 
Sometimes it acts so powerfully, that the hand of the ac- 
coucheur, introduced to execute a manoeuvre, is benumbed, 
and sensation and motion are instantly lost, 



OF TOUCHING. 

Among the modes of determining the existence of preg- 
nancy, touching is the most essential, as it unites all the 
conditions requisite to establish the sensible and positive 
signs of pregnancy. Considered in this respect, touching 
may be defined a manual operation, the object of which is 
to ascertain the changes in the situation, the figure, and the 
consistence of different parts of the uterus, not only during 
pregnancy, but also during and after parturition. In order 
that this operation may be successful, the index finger of 
one hand must be introduced into the vagina, t-o discover 
the state of the neck, the opposite hand being applied to the 
abdomen, to judge how much the uterus is developed, and 
from combining these two modes of investigation, to form 



MIDWIFEPY ILLUSTRATED. 95 

an opinion of the existence of pregnancy, and then to 
determine the period of gestation. 

The female may be touched in an erect or horizontal 
posture : the manner of touching differs in these two cases. 

Of touching 1 — the female standing. This mode is advan- 
tageous in every respect. The parts of the female are in 
their natural position, and the accoucheur cannot be mis- 
taken. The mode of proceeding is as follows : the female 
stands erect; her back supported by some vertical plane, 
should remain motionless during the operation : her legs 
are separated, and the pelvis carried forward ; the hands 
hang down, or are gently crossed on the abdomen ; and the 
whole form should be perfectly at ease. The accoucheur 
then oils the index finger of one hand, introduces it by the 
posterior commissure within the vagina, passes it up to 
the neck of the uterus, which is generally situated to the 
right and backward: by examining carefully, he determines 
its extent and size, its degree of resistance and flaccidity : 
if the os tincoe be open, the end of the finger is carefully 
introduced, to judge how much it is shortened, and thus to 
determine the period of pregnancy; the neck not being 
able to yield thus and to lose its extent and resistance with- 
out contributing to the dilatation of the uterus, and thus 
concurring in its enlargement. {See PL XXXII.) While 
the accoucheur thus passes the index finger within the 
vagina, he must place the palm of the opposite hand on the 
abdomen, to judge of the changes produced by the progress 
and development of pregnancy, in the figure and size of the 
uterus : he must also determine the height to which the 
uterus has risen, by pressing slightly on that part of the 
abdomen, to which its base corresponds. 

We have now to mention the mode of ascertaining the 



96 MIDWIFERY ILI ^STRATED. 

presence of the child in the uterus, and how ballottement 
may be performed: we proceed in the following manner. 
We easily see a depression between the neck and the adja- 
cent part of the bladder, to the base of which the lower 
part of the uterus corresponds: the head of the fetus is 
generally situated near this point, after the fourth month of 
pregnancy : here also the accoucheur must place the extre- 
mity of his finger, while the opposite hand is applied to that 
part of the abdomen where the base of the uterus is 
situated; then by an alternate action, sometimes by the 
hand placed on the abdomen, sometimes by the finger in the 
vagina, he raises and depresses the child. This is called 
ballottement. (See PL XXXI.) 

Ballottement can rarely be performed until the fourth 
month of pregnancy ; before this time, the head of the child 
is too small, and the quantity of the waters of the amnios 
proportionally too great, to perceive it through the parietes 
of the uterus. Ballottement is most easily performed from 
the fourth to the seventh month, as the head is then more 
elastic. Farther, this phenomenon, so wonderful in its 
effects, not only demonstrates the certainty of pregnancy, 
but also that the child is living ; since a dead fetus never 
responds as promptly and lightly to the motions impressed 
upon it. 

After the seventh month, and in the latter periods of 
pregnancy, the head of the child becomes heavier, and as 
the quantity of the waters of the amnios diminishes in- 
versely, it follows that ballottement is then very difficult, 
and even impossible : this, however, only becomes a still 
stronger proof of pregnancy, as the child's head then occu- 
pies most of the superior strait, in which it seems already 
engaged, and the finger easily passes over its whole surface. 







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Of touching } — the female reclining. The mode of touch- 
ing while the female is reclining, differs a little from that 
just mentioned, and must be practised when ever the pre- 
ceding mode would not afford the same results. It is most 
advantageous during the first three or four months of preg- 
nancy. During labor, both methods can be employed with 
the same success : but after parturition, and during the 
period of lying-in, the female to be touched must always be 
in a horizontal posture, and consequently lying down. In 
order to practice it successfully, the head of the female 
should be gently flexed on the chest, the legs upon the 
thighs, which are slightly separated. The accoucheur 
should stand on the right side of the female, if he touches 
with the right hand, and vice versa, if the left hand be 
used : the index finger of one hand is introduced into the 
vagina, as before, and the other hand is placed upon the 
abdomen. But as the neck exhibits no indication of preg- 
nancy until the fourth month, he must merely raise the body 
of the uterus, balancing it slightly between the two hands, 
while he executes this operation. 

No advantage can be derived from placing the hand upon 
the abdomen daring labor : the finger introduced into the 
vagina is alone sufficient to make known whatever precedes 
and accompanies the termination of labor. This is not 
true, however, after the child is born, and during the lying- 
in. In the latter case, it is often necessary to introduce an 
index finger into the vagina, and to examine if the uterus 
has contracted, by placing the hand at different times on 
the abdomen. 

12 



OF LABOR. 



In labor we must consider, 1st, its definition; 2d, its 
division ; 3d, its causes ; 4th, its phenomena ; 5th, its 
termination. 

1. Definition. We define labor, a natural function, by 
which the female gives birth to a living, full-grown and 
healthy child. 

2. Division. Labor is divided according to the period 
when it occurs, and the manner in which it terminates. 

In regard to the period; when it occurs before the 
fifteenth day of pregnancy, it is termed an efflux : when 
before the seventh month, an abortion : premature labor, 
when occurring from the seventh to the ninth month : and 
natural or common labor, when terminating at the ninth 
month. 

Every author has made a more or less arbitrary classifi- 
cation of labor, from the manner in which it terminates : 
these classes are frequently unsanctioned by reason, and 
disavowed by practice. A good classification of labors 
must be founded on the nature of the means used for their 
termination, and not on vague expressions. 

3. Causes of labor. The causes of labor are proximate 
or efficient, remote or determinate. 



MIDWIFERY ILLUSTRATED. 99 

The proximate or efficient causes are, those which appear 
at the moment of labor, and which in a measure preside at 
its termination. They may be divided into natural, common 
or general, and accidental, unforeseen or individual. The 
latter also are subdivided into external and internal. Of 
the first kind, are blows, falls, compression, &c: to the 
second, belong the lively emotions of the mind; as fear, 
anger, &c. 

The remote or determinate causes are not specified so 
easily. They, in turn, have been ascribed to the size of the 
child, the acridity of the waters, the impossibility of a 
greater dilatation of the uterus, the necessity which the 
child has for breathing, eating, &c. These, however, are 
by no means the true determining causes of labor : they 
consist in the progress and development of pregnancy. 

4. Phenomena of parturition. Of these, four are admitted 
as principal : they are, pain, dilatation of the neck of the 
uterus, formation of the bag of waters, and discharge of 
glairy mucus. 

5. Termination. The termination of labor may be 
natural or artificial. It is natural, when finished by the 
contractions of the uterus alone : it is artificial, when art 
interposes, and one of the means which compose the ma- 
noeuvre is employed. In this place, we shall treat only of 
natural labor, which is properly termed parturition. 

Labor may terminate naturally in four different ways ; 
by the head, by the feet, by the knees, and by the breech. 

In order that the labor should terminate naturally, several 
circumstances must concur, some of which concern the 
mother, and others the child : in regard to the mother, she 
must have sufficient strength and courage to second the 
efforts inseparable from the labor of child-birth : the differ- 



100 MIDWIFERY ILLUSTRATED. 

ent diameters of the pelvis also must be large enough to 
allow the head to pass, and both the internal and external 
organs of generation must offer no obstacle. 

In regard to the child, the dimensions of the head must 
be in proper proportion with those of the pelvis, and the 
occiput must present at the superior strait. 

A. Presentation of the head. The head, the occiput 
presenting, may be placed in four different ways at the 
superior strait : hence the four kinds of natural presenta- 
tions of the head. In the first, the occiput is situated for- 
ward and to the left, and corresponds to the inner part of 
the cotyloid cavity of the left side, and the face looks toward 
the right sacro-iliac symphysis : this is the left occipito-cotyloid 
position. (See PL XXXIII. Fig. 1.) In the second, the 
occiput is placed to the right and forward, and corresponds 
to the inner part of the right cotyloid cavity : this is the 
right occipito-cotyloid position. (See PI. XXXIII. Fig. 2.) 
In the third, the occiput is situated backward and to the 
right, and corresponds to the right sacro-iliac symphysis : 
this is the right occipito- sacro-iliac position. (See PL 
XXXIV. Fig. 1.) In the fourth, the occiput is placed to 
the left and backward, and looks to the left sacro-iliac 
symphysis : it is the left occipito-sacro-iliac position. (See 
PL XXXIV. Fig. 2.) 

First position of the vertex. In this presentation, the 
sagittal suture is in relation with the oblique diameter of 
the pelvis, which proceeds from the inner part of the left 
cotyloid cavity, to the right sacro-iliac symphysis. In con- 
sequence of the labor, and the contractions of the uterus, 
the head vibrates in this position, by which motion the 
posterior fontanelle, which is forward, describes a line 
curved from above downward, and from the left forward, to 



MIDWIFERY ILLUSTRATED. 101 

come towards the sub-pubic opening, while the anterior 
fontanelle, which is situated posteriorly, also describes a 
curved line in an exactly opposite direction. By this mo- 
tion, the occiput is depressed under the symphysis pubis, 
while the chin tends to re-ascend towards the sacro- 
vertebral prominence, being bent forcibly on the chest; 
this diminishes the antero-posterior diameter of the head in 
the same proportion, which being then situated between the 
two tuberosities of the ischium, soon projects from the 
external organs of generation. It now appears in the form 
of a rounded, shining, and more or less bulging tumor. 
The accoucheur must be very careful to sustain it by 
placing the hand across the perineum, (as is seen in PL 
XXXV. Fig. 1.) in order that the child's head, which is 
then pushed forward by very rapid and quick contractions, 
may be properly directed, and escape unimpeded, through 
the external organs of generation, following the direction 
of the axis of the inferior or perineal strait, 

When once emerged, the head moves quickly, so that the 
occiput is turned towards the inner part of the left thigh : 
at the same time, the shoulders, which constantly remained 
in the direction of the oblique diameter, opposite to that 
occupied by the head at the superior strait, are placed, on 
entering the cavity, the right behind the symphysis pubis, 
and the left in the hollow of the sacrum. 

Second position of the vertex. In this position, which is 
the most common next to the first, the sagittal suture is 
situated diagonally in the direction of the oblique diameter, 
which extends from the right cotyloid cavity to the left 
sacro-iliac symphysis. The posterior fontanelle looks for- 
ward, and the anterior fontanelle backward, as in the 
preceding position. 



102 MIDWIFERY ILLUSTRATED. 

The mechanism of labor takes place exactly as in the first 
presentation, with this difference however : that when the 
head of the child is delivered, the occiput is turned to the 
right, as it was to the left in the preceding case. In this 
position the shoulders appear and the labor terminates 
precisely as in the first. 

Third position of the vertex. In this, as also in the next 
position, the head is situated at the superior strait, directly 
opposite to what it was in the first and second positions ; 
in these latter, the occiput was situated at the anterior 
part of the pelvis; in the last two, it looks towards its 
posterior part. 

As the head progresses through the pelvis, the posterior 
fontanelle is depressed in the cavity of the sacrum, while 
the anterior, on approaching the arch of the pubis, con- 
stantly rises towards the symphysis pubis. As the labor 
advances, and the contractions of the uterus become more 
lively and expulsive, the occiput is forced towards the 
perineum, distends it very much, forming through it a pro- 
jecting tumor. The forehead is then situated under the 
arch of the pubis, and presents a point of support to the 
head, and thus favors its final expulsion, forcing the occiput 
towards the more or less distended vulva. 

The head, when delivered, is situated on the side, and 
the occiput is turned towards the inner part of the right 
thigh. The shoulders soon present themselves at the 
vulva, the left under the arch of the pubis, and the right 
towards the posterior commissure : they are soon followed 
by the rest of the child, which is thus born face upward. 

Fourth position of the vertex. In this position, the sagittal 
suture is parallel to one of the oblique diameters of the 
pelvis, the posterior fontanelle is situated to the right and 



MIDWIFERY ILLUSTRATED. 103 

backward, and the anterior fontanelle to the left and for- 
ward. In this position, the mechanism of labor is the same 
as in the third ; the occiput proceeds by a rotatory motion, 
into the hollow of the sacrum, while the forehead con- 
stantly rises towards the symphysis pubis. In consequence 
of this double motion, the occiput projects across the more 
or less distended perineum. But the occiput soon rises 
towards the vulva, while the face glides behind the pubis, 
and the head finally emerges as we have stated : in this 
last position, the occiput turns to the right instead of the 
left, as in the third position. 

B. Natural presentation of the feet. When the feet of 
the child present at the superior strait, they may be placed 
in four different ways ; hence four special positions. 

First position of the feet. In this position, the heels look 
towards the left cotyloid cavity, and the toes to the right 
sacro-iliac symphysis : the posterior parts of the child are 
situated forward and to the left of the uterus. (See PI. 
XXXVI. Fig. 1.) 

As soon as the membranes are ruptured, the feet, and the 
rest of the lower extremities, are easily delivered. At this 
time, the left haunch looks towards the right cotyloid 
cavity, and the right haunch to the left sacro-iliac sym- 
physis. The child, however, continues to descend, and the 
arms, which soon rise on the sides of the neck and head 
serve to fix it diagonally, so that the occiput looks to the 
left cotyloid cavity, and the forehead to the right sacro-iliac 
symphysis. The head soon passes into the cavity of the 
pelvis, rotating from the left forward, so that the occiput 
describes an arch under the symphysis pubis, while the 
face, and particularly the forehead, proceed in an opposite 
direction towards the cavity of the sacrum. Finallv, the 



104 MIDWIFERY ILLUSTRATED. 

occiput passes from below the symphysis; the chin also 
performs a parabolic motion from above downward, which 
carries it to the posterior commissure ; a last effort expels 
the head and the upper extremities, and the labor terminates. 

Second position of the feet. Here the heels look to the 
right cotyloid cavity, and the toes to the left sacro-iliac 
symphysis ; the posterior parts of the child are forward and 
to the right. Since the mechanism of labor is exactly the 
same as in the preceding position, we shall not dwell upon 
it ; we shall only remark that the child, in proportion as 
labor advances, is always situated obliquely, so that the 
right side is constantly in relation with the left cotyloid 
cavity, and the left side with the right sacro-iliac sym- 
physis. It is not until birth, that the head rotates, so that 
the occiput is situated under the symphysis pubis, and the 
face in the cavity of the sacrum. 

Third position of the feet. In this position, the heels look 
to the right sacro-iliac symphysis, and the toes to the left 
cotyloid cavity: the posterior surfaces are situated back- 
ward and to the right : in the fourth, the same surfaces look 
backward and to the left. 

The mechanism of labor, in the third, as well as in the 
fourth position of the feet, is performed exactly as in the 
first two, until the breech presents. Then only the anterior 
surfaces of the child constantly remain upward, and when 
the head descends into the cavity, the forehead is situated 
behind and under the arch of the pubis, while the occiput 
is depressed into the cavity of the sacrum, and passes 
through its whole extent, as well as the perineum, which is 
more or less distended. The occiput escapes the first, after 
passing through the posterior commissure : the face is then 



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disengaged slowly, and without effort, from below the 
symphysis pubis, and the labor terminates. 

Presentation of the knees. As this labor differs but 
slightly, or not at, all, from that which terminates by the 
feet, we shall omit it. 

Presentation of the breech. In the first position, the back 
looks directly to the left, and in the second to the right : 
the difficulty of establishing the characters of the third and 
fourth positions, obliges us to describe only the first and 
second. 

In both positions, the child is doubled ; the lower extre- 
mities are extended on its anterior surface. {See PI. 
XXXVI. Fig. 2.) 

The mechanism of labor is performed as follows : the 
breech is pressed by the contractions of the uterus, and 
is engaged, although with great pain, on account of its 
size, in the superior strait. If the labor continues, one of 
the haunches glides under the arch of the pubis, while the 
other passes slowly and with difficulty through the cavity 
of the sacrum, and thus comes to the posterior commissure. 
The thighs are then bulging, and the external organs of 
generation very much distended. The meconium often 
escapes, which confirms the presentation of the breech. 
While this latter is passing through the vulva, the arms 
are raised, and the head is soon engaged obliquely in the 
superior strait, through which it passes, as when the feet 
present. 

13 



OF THE MANOEUVRE. 



We define the manoeuvre, a manual operation, by which 
a labor is terminated, when nature alone is insufficient. 
The manoeuvre is divided into simple, compound, and com- 
plex : it is simple, when the labor is terminated by the 
hand alone : it is compound, when some instruments are 
necessary, as the forceps, lever, &c. : finally, it is complex, 
when some capital operation of obstetrics must be employed, 
as hysterotomy, symphysiotomy, &c. 

The causes which oppose the natural termination of 
labor, and require the employment of some manoeuvre, are 
of two kinds : the first, depends on the unfavorable situa- 
tion of the child at the abdominal strait ; for instance, when 
the back, or belly, &c, present : the second, results from 
unforeseen accidents, and severe symptoms supervening sud- 
denly during the labor. In the first rank must be placed 
these causes : first, hemorrhage ; second, convulsions; third, 
extreme debility, and repeated faintings ; fourth, spasmodic 
contraction of the neck of the uterus ; fifth, insertion of the 
placenta on the neck or edges of the uterus ; sixth, prema- 
ture expulsion of the umbilical cord ; seventh, its shortness ; 
eighth, the extreme obliquity of the uterus ; ninth, irredu- 
cible hernia ; tenth, unnatural size of the child's head ; 



MIDWIFERY ILLUSTRATED. 107 

eleventh, compound pregnancy; twelfth, a defect in the 
pelvis, or in the external organs of generation. 

In every manoeuvre there are four principal periods. 
1st, the period of introducing the hand ; 2d, that of explo- 
ration ; 3d, that of turning ; 4th, that of delivery. 

1. Period of introduction. The female being placed in a 
proper position (See PL XXXV. Fig. 1 and 2.), the accou- 
cheur oils one hand, and introduces it, partly bent, into the 
vagina, slightly separating the external labia by the poste- 
rior commissure : when once in the cavity, the hand is 
extended, and the index finger is directed towards the neck 
of the uterus, introducing the whole hand into the vagina, 
if it be sufficiently dilated. If this be not the case, he 
dilates it gradually, inserting successively the fingers of the 
hand, commencing with the index finger ; in this manner, 
he arrives at the uterus. 

2. Period of exploration. This second period is undoubt- 
edly the most important, since the success of the termination 
of the labor depends on the precise knowledge of the parts 
of the child which present at the orifice. The parts then, 
on which the fingers are placed, must be explored with 
care, in order not to mistake the breech for the shoulder, 
the elbow for the knee, &c. ; and lastly, the hand must be 
placed so as to arrive at the feet in the shortest and easiest 
way. 

3. Period of turning. The hand having arrived at the 
feet, seizes them, and attempts to bring them to the orifice 
of the uterus, by moving the child so as to carry its anterior 
surface upward. In this motion, which is generally the 
laborious part of the manoeuvre, the accoucheur should be 
particularly careful not to cross the child's limbs upon one 
another, and he ought not to bend them in an unnatural 



108 MIDWIFERY ILLUSTRATED. 

direction. Fractures of the limbs are caused solely by 
forgetting this precept. 

4. Period of delivery. The feet are brought to the supe- 
rior strait, and the child is placed in one of the diagonal 
positions favorable to its expulsion, and the accoucheur 
delivers it as we proceed to state. 



OP THE SIMPLE MANOEUVRE. 

The simple manoeuvre is divided into three sections : the 
first includes those labors in which the child presents some 
part of the lower extremities; the second relates to the 
different presentations of the trunk ; and the third to those 
of the head. 

Presentation of the lower extremities. It includes the pre- 
sentation of the feet, the knees, and the breech. 

A. Presentation of the feet. When the feet present, the 
child may be placed in four different ways, whence result 
four positions of the feet. 

In whatever position the feet may be placed, their cha- 
racters must be recognized, in order to distinguish them 
from the hands, with which, being very analogous, they 
may be confounded. Thus it should always be remem- 
bered, that the foot is longer and narrower than the hand ; 
that it terminates at one extremity by a prominent part, the 
heel ; that at the opposite extremity are the toes, which are 
short, even, and very near each other, while the contrary is 
true of the fingers ; finally, that the foot makes an acute 
angle with the leg, while the hand is a continuation of the 
fore-arm. 



MIDWIFERY ILLUSTRATED. 109 

First position of the feet, or the left calcaneo-cotyloid "position. 
In this position, the heels look toward the inner part of the 
left cotyloid cavity, and the toes to the right sacro-iliac 
symphysis ; at the termination of labor, the whole posterior 
surface of the child should progress parallel to a line, which 
is imagined to leave the cotyloid cavity, and to terminate 
at the occiput. In this position, the left hand must be 
introduced as most favorable to terminate the labor : this is 
termed the hand of necessity. (See PL XXXVII. Fig. 1.) 

The left hand is introduced into the uterus ; the child's 
feet are seized by placing the index finger in the space 
between the two feet, above the malleoli; the thumb is then 
extended on the outside of the left leg, and the last three 
fingers of the same hand on the outside of the right leg. 
We then pull slightly, and deliver the feet : this done, they 
are seized with both hands, and by moving them gently 
from right to left, the different parts of the child are brought 
down, until the thighs begin to present at the external 
organs. We now suspend our efforts for a moment in order 
to ascertain the situation of the umbilical cord, which must 
be formed with a knot, pulling more particularly upon its 
placental portion. Having executed this, two fingers of the 
left hand are placed on the left haunch of the child, and two 
fingers of the right hand on the right haunch. (See PL 
XXXVII. Fig. 2.) The child is now brought successively 
from the right groin of the mother to the inner part of the 
left thigh, being constantly kept in a diagonal position. 
This alternate motion is continued, until the shoulders 
begin to present externally : the arms must then be deli- 
vered. We must always commence by the one which is 
downward : we support the child on the left fore-arm, glide 
two fingers of the right hand along the child's arm to the 



HO MIDWIFERY ILLUSTRATED. 

elbow, then by a motion of circumd action, it is carried 
successively over the sides of the head, the face, the neck, 
the chest, and then delivered, bringing it out from the right 
side of the vulva. The child is now depressed on the right 
fore-arm, and the left arm of the child, which is down- 
ward, is delivered by employing the same means as for 
the right arm. (See PL XXXVIII. Fig. 1.) 

When the arms are delivered, the head is still above the 
superior strait, and its delivery is by no means the easiest 
part of the manoeuvre. To perform it, the left hand is 
introduced into the vagina, gliding it along the anterior 
surfaces of the child, which look downward ; two fingers 
are placed upon the upper jaw, below the nose ; two fingers 
of the other hand upon the occiput, which is above ; then 
by a double motion, viz. extracting the head, and depressing 
the face on the chest, the head is brought into the small 
pelvis without changing its diagonal position ; now, by 
rotating it a quarter of a circle, the occiput is placed behind 
the symphysis pubis, and the face in the cavity of the 
sacrum: and lastly, by moving it from right to left, and 
depressing it, the occiput is supported under the symphysis 
pubis, while the left hand is applied to the perineum, and 
raises the head, which is disengaged from the external 
organs still more, and is delivered ; the labor is now ter- 
minated. (See PL XXXVIII Fig. 2.) 

Second position of the feet, or right calcaneo-cotyloid position. 
The general situation of the child in the second position, is 
the same as in the first : the heels, however, look to the 
right cotyloid cavity, the posterior surfaces of the child 
being in relation with the right lateral and slightly anterior 
portion of the uterus. 

The right hand, which is either the hand preferred, or 



MIDWIFERY ILLUSTRATED. Ill 

that of necessity, seizes the two feet, placing the fingers as 
in the first position, and brings them down. The child 
being delivered as far as the thighs, the umbilical cord is 
then taken and used as a handle, pulling rather on its 
maternal portion. The child is then seized, the accoucheur 
placing his hands on the haunches, and by moving it 
alternately from right to left, it is delivered as far as the 
shoulders; the arms are disengaged as before, the right 
hand is introduced into the vagina, two fingers are placed 
below the child's nose, and the opposite hand on the occiput, 
and by the double motion mentioned above, the head is 
brought into the cavity of the lower pelvis, whence it is 
delivered, the mechanism being the same as in the first 
position. 

Third position of the feet, or right calcaneosacro-iliac 
position. In this position, the heels look to the right sacro- 
iliac symphysis, and the toes to the left cotyloid cavity : 
the posterior surfaces of the child along the right lateral and 
slightly posterior portion of the uterus : it is the opposite of 
the first. The child's feet are seized with the right hand : 
they however are not delivered immediately, but the child 
is turned, and thus the anterior surfaces are carried down- 
ward. The position of the child is then the same as in the 
second position, and the labor is terminated precisely in the 
same manner. 

Fourth position of the feet, or left calcaneo-sacro-iliac 
position. The heels correspond to the left sacro-iliac sym- 
physis, and the toes to the right cotyloid cavity: it is the 
reverse of the second position. The feet are grasped with 
the left hand ; as they are delivered, the child is turned, so 
that the anterior surfaces are carried downward, and the 
labor is terminated as in the first position. 



112 MIDWIFERY ILLUSTRATED. 

B. Presentation of the knees. In this species of labor the 
manoeuvre differs but little from that where the feet present. 
We might pass this presentation without pointing out its 
characteristics, which also require some details on the 
application of the fillet. 

The knees may be distinguished by the presence of two 
rounded tumors, beyond which we find two elongated parts, 
the thigh and the leg. In the four positions of the knees, 
the general situation of the child is the same as when the 
feet present. (See PL XXXIX. Fig. 1 and 2.) 

In both positions of the knees, the palmar face of the 
hand introduced, must correspond to the anterior surfaces 
of the child, and the knees must be seized as they present : 
the feet cannot be disengaged until the knees are delivered, 
and the labor is then terminated as in presentations of the 
feet. 

When it is difficult to reach and grasp the knees with one 
hand, a fillet is passed round the calf of the leg which is 
below, the two ends of which are brought out, and thus the 
lower extremities are easily delivered. 

If the fillet cannot be applied on account of the height 
of the knees, the blunt hook may be used, which might 
even be applied on the calf of the leg which is below, and 
with which it may be delivered. 

C. Presentation of the breech. All authors have admitted 
four different positions of the breech, but they do not agree 
in their distinctive marks. This difference of opinion 
depends on the difficulty of defining the third and fourth 
positions admitted by Beaudeloque. We, therefore, shall 
mention here but the first and second, the only ones really 
found in practice. In both cases we suppose the child to 



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MIDWIFERY ILLUSTRATED. 113 

be doubled, that is, the lower limbs to be raised on the 
anterior part of the trunk. 

The characters of a breech presentation are, a broad 
tumor occupying the whole extent of the strait, and more 
or less yielding, according to the degree of the contraction 
of the parts, and the length of time that the child has been 
engaged in the superior strait. Sometimes the two tube- 
rosities of the ischium may be felt, but the extreme swelling 
of the breech often conceals them : the anus, however, is 
always situated in the centre of the tumefied surface ; but 
we must be careful not to confound it with the mouth, and 
mistake a presentation of the face for one of the breech. 

First position of the breech. The child being doubled, as 
we stated above, is situated so that the back and the head 
look directly to the left iliac fossa, and the lower limbs, 
which are raised on the trunk, to the right iliac fossa : the 
left haunch corresponds to the symphysis pubis, and the 
right haunch to the sacro-vertebral angle. 

The left hand is carried as high as the thighs ; it grasps 
them firmly, brings them into the cavity in order to disen- 
gage the feet and terminate the labor in the same manner 
as when the feet present : but if it be too difficult to execute 
the manoeuvre in this manner, we can always slightly push 
them back with the left hand carried as high as the thighs : 
we then glide the hand towards the lower extremities, and 
disengage them together or separately to place the child in 
the first position of the feet, and terminate the labor in the 
mode already mentioned. 

Second position of the breech. In this the situation of the 
child is the opposite of the first ; and the right hand must 
be introduced to terminate the labor as in the second 
position of the feet. (See PL XL. Fig. 1 and 2.) 



14 



114 MIDWIFERY ILLUSTRATED. 



PRESENTATIONS OF THE TRUNK. 

This section comprises those labors in which some one of 
the large surfaces of the child are presented : it includes 
presentations of the back, belly, thorax, breech, and shoul- 
ders, complicated with the appearance of the whole or a 
part of the arm. The termination of the labors treated of 
in this section forms essentially what is termed the 
manoBuvre. 

The fundamental character of the manoeuvre relative to 
the termination of labor when some one of the lower 
extremities presents, is that the child is delivered by seizing 
the parts which present, and bringing them down. This is 
not the case, however, with the manoeuvre when the trunk 
presents: it is impossible to bring the child through the 
bony pelvis as it is situated at the superior strait, for, as is 
commonly said, it is placed across, and it must necessarily 
be returned and then brought outward. In this consists the 
whole secret of the manoeuvre, generally, in which the feet 
of the child are brought down to the superior strait by the 
shortest and easiest way. In the manoeuvre where the 
lower extremities are concerned, the period of turning is 
never used : this, however, is indispensable in presentations 
of the trunk, as the feet of the child are always more or 
less remote from the superior strait, and cannot be seized 
until we have passed over a greater or less part of the 
external surface of the child. Finally, if in these presenta- 
tions we examine the causes which require the employment 
of the manoeuvre to terminate the labor, no other motive 
must be regarded in deciding to use it, except the unfa- 



MIDWIFERY ILLUSTRATED. 115 

vorable position of the child, which thus prevents its free 
and natural delivery. 

Before proceeding to mention the manoeuvre particularly, 
we would state, that we admit only two positions for each 
of the presentations of the trunk. 

A. Presentation of the back. Under this term we in- 
clude several other kinds of presentations admitted by 
authors, which we reject, because they terminate in the 
same way. 

In both positions of the back, the child is situated cross- 
wise above the strait ; the head is placed on one of the iliac 
fossae, and the feet on the opposite one; the anterior surfaces 
look upward. 

The distinctive marks of this presentation are, a broad 
glistening tumor, which presents lengthwise from right to 
left a prominent spine formed by the successive spinous 
processes of the vertebrae : on one side, the edges of the 
false ribs, on the other, the scapulae, are sufficient signs to 
aid the accoucheur in his examination, and to indicate even 
the special or peculiar situation of the child. 

First position of the back. The child being situated cross- 
wise, the head rests on the left and the feet on the right 
iliac fossa. The right hand is introduced in the state of 
supination, grasps the child and turns it slightly on itself, so 
that the back is brought towards the symphysis pubis. The 
hand is then carried entirely on the anterior surfaces of the 
child, and after passing successively over the belly and the 
anterior part of the thighs, seizes the knees, and brings 
them and the feet towards the right cotyloid cavity, in order 
to place the child in the second position of the feet, to 
terminate the labor as in this latter. {See PL XLI. Fig. 1.) 

Second position of the back. In the second position, the 



116 MIDWIFERY ILLUSTRATED. 

situation of the child is opposite to what it is in the first, 
Consequently, the left hand must be introduced to terminate 
the labor, which is done as in the first position of the feet. 
(See PL XLI. Fig. 2.) 

In either of the positions of the back, when the feet are 
seized, as already directed, the child turns on itself with 
the utmost facility, and then only natural and easy motions 
are executed. 

B. Presentation of the belly. In proportion as the situa- 
tion of the child was fortunate and natural in the presenta- 
tion of the back, just so is it irksome and dangerous when 
the belly presents. In fact, in this presentation, the child 
is very much bent in an unnatural direction, and if it con- 
tinues so for a long time, it will be in great danger. 

This presentation is easily known : the presence of the 
umbilical cord, of which a greater or less portion often pro- 
trudes, indicates it unequivocally, or only generally : for to 
know the exact position, the accoucheur must necessarily 
pass his finger to the right and left, in order to feel the edge 
of the false ribs, and the crest of the iliac bones, and also 
the genital organs. 

In the presentation of the belly, as in that of the back, 
the child is situated across the superior strait, the face on 
one of the iliac fossae, and the feet on the other. 

First position of the belly. The child is situated across 
the strait, so that its head looks to the left iliac fossa, and 
its feet to the right. The right hand is introduced into the 
uterus, and placed on the right side of the child ; it then 
passes over all the posterior surface to the feet, which are 
brought down separately or together into the cavity to ter- 
minate in the second position of the feet. (See PL XLII. 
Fig. 1.) 



MIDWIFERY ILLUSTRATED. 117 

Second position of the belly. In this also the child is 
situated across the strait, but opposite to the first position. 
Here the left hand must be introduced, and placed in the 
same way as in the first position : it terminates like the first 
position of the feet. (See PL XLIL Fig. 2.) 

It often happens that only one foot can be brought down, 
the other being too far to be reached : in this case, a fillet 
must be tied upon the foot which is delivered, to keep it 
from returning, and the same hand must be introduced 
again in search of the other foot, which should be brought 
into the cavity in the same manner as the first was. 

C. Presentation of the chest or thorax. In this presenta- 
tion, the general position of the child is exactly the same as 
in the presentation of the belly : the same unnatural curve 
exists, the same danger to the child, and the same diffi- 
culty in the manoeuvre. But as the feet are farther from 
the strait, and as the head is a little nearer, some practi- 
tioners have advised to turn by the head, which w T ould thus 
be brought into the cavity, instead of seeking for the feet, 
which it is very difficult to reach. We do not absolutely 
reject this method, but we are far from adopting it exclu- 
sively, for the following reasons. When the membranes are 
not ruptured, nor the waters evacuated, or shortly after the 
escape of the waters, as the uterus has not had time to 
contract, we can conceive it possible to bring the head to 
the brim, and then to leave it to the contractions of the 
uterus, which in fact will soon force it into the cavity, and 
expel it. If this could be done in every case where the 
trunk presents, it would doubtless be preferable to turning 
by the feet : but it is inadmissible in case of inertia of the 
uterus, hemorrhage, convulsions, or any other more or less 
formidable symptoms. 



118 MIDWIFERY ILLUSTRATED. 

In turning by the feet, we are always certain to termi- 
nate the labor, when they are seized properly, since we 
direct the labor : there is not the same advantage in turn- 
ing by the head, for independent of the difficulty of attaining 
it, and of bringing it to the superior strait, the slightest 
defect in the relation between it and this latter, may 
prevent the termination of the labor. How cruel the 
alternative, to be obliged sometimes, after a long and painful 
manoeuvre, to turn by the feet ! 

First position of the chest. The head is on the left, the 
feet on the right of the pelvis. The right hand is intro- 
duced, as in the first presentation of the abdomen, and we 
search for the feet, which is very tedious, as they are dis- 
tant. But when once in the cavity, they are easily dis- 
engaged, either separately or together, and the labor is 
terminated as in the first presentation of the feet. (See PL 
XLIIL Fig 1.) 

Second position of the chest. The general position of the 
child is the same, but the head is on the right, the feet on 
the left. The left hand searches for the feet, brings them 
into the cavity, and the labor is terminated as in the first 
presentation of the feet. (See PL XLIIL Fig. 2.) 

D. Presentation of the haunches , or sides of the child. 
Under this general term, we include the presentation of the 
haunches and that of the ribs ; because the side, properly 
speaking, presents no determinate character, and in order 
to recognize it, we are always obliged as a guide to go to 
the haunch, which is sometimes hard to be distinguished. 
Finally, when this last part presents, there is a small 
rounded tumor, which presents nothing characteristic, hence 
we must pass the finger sometimes backward, sometimes 
forward, to discover first, the spinous processes of the last 



MIDWIFERY ILLUSTRATED. 119 

lumbar vertebrae ; second, the genital organs of the fetus, 
and also the crest of the ilium. 

But beside the general characters of the presentation of 
the haunch, we must mention also the peculiar marks of 
each, so as not to confound the right with the left, which 
would necessarily cause much uncertainty and confusion in 
the manoeuvre. 

First position of the right haunch. The child is situated 
crosswise, as in all the presentations of the trunk ; its pos- 
terior surface looks to the symphysis pubis, and the anterior 
to the sacro-vertebral prominence. The head is situated to 
the left, the feet to the right. The right hand is introduced 
in a state of supination; after gently pushing back the child, 
it glides successively over the whole anterior surface to the 
feet, which are seized and easily brought down into the 
cavity, and the labor terminates as in the second presenta- 
tion of the feet. 

Second position of the right haunch. The child lies cross- 
wise, the head to the right and the feet to the left : the pos- 
terior surface is backward and downward, the anterior for- 
ward and upward. The left hand is introduced in a state 
of pronation ; it gently pushes back the child, glides over 
the whole anterior surface to the feet, which are slowly 
brought into the cavity, to facilitate the turning of the child 
on itself. Too much haste would infallibly injure the 
success of the manoeuvre. (See PI. XLIV. Fig. 1 and 2.) 

First position of the left haunch. In this presentation, the 
general position of the child is the same as in the first posi- 
tion of the right haunch : as in this latter, the child's head 
rests on the left iliac fossa, and the feet look to the right iliac 
fossa; but they differ in this position, as the anterior surfaces 
of the child which are turned towards the pubis, are upward, 



120 MIDWIFERY ILLUSTRATED. 

and render the manoeuvre as difficult as that of the second 
position of the right haunch, to which it is very analogous as 
respects the special situation of the fetus. To perform it, 
the right hand is introduced, and after pushing back the 
child, it is bent on its anterior surface, and passes over it to 
the feet ; these are then brought towards the superior strait, 
by pulling principally on the most remote, in order to favor 
the motion of turning the child, by which the anterior sur- 
faces are brought downward. When the feet are once in 
the cavity, the labor is terminated as in the second position 
of the lower extremities. 

In this position, as in the second presentation of the right 
haunch, we must proceed very slowly and carefully, if we 
wish to succeed ; for if too much precipitation or violence 
be used, the labor cannot probably be terminated without 
danger to the child, and frequently also to the mother. 

Second position of the left haunch. This position has the 
most perfect analogy with the first of the right haunch, as 
respects the general position of the child ; the head, how- 
ever, is to the right of the pelvis, the feet to the left, the 
anterior surfaces of the child looking downward. 

The left hand is introduced, the child is gently pushed . 
back, and then the hand is passed over the anterior surface 
to the feet, which are seized, and the labor is terminated as 
in the first position of the feet. (See PL XL V. Fig. 1 and 2.) 

E. Presentation of the shoulder •, complicated ivith the ap- 
pearance of a part or the whole of the arm. This presenta- 
tion differs from the preceding, not only on account of the 
presence of the shoulder, the slightly marked characters of 
which have a very great analogy with the other parts of 
the child, but particularly on account of the appearance of 



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MIDWIFERY ILLUSTRATED. 121 

the arm by which the termination of the labor is always 
very much impeded. 

In order to proceed methodically, we shall first describe 
the presentation of the shoulder as if the child had no arm. 
It is the only way to form a correct idea of this presentation 
and of the manoeuvre proper for it. 

The general characters of the presentation of the shoul- 
der are, a small shining tumor, rather similar at first view 
to that presented by the elbow, the knee, the thigh, and 
even the breech; its special characters have no peculiar 
marks. But if the index finger be carried a little farther, 
we soon discover on one part the scapula, and on the other 
the clavicle, as also the upper ribs, which confirm the special 
character of the presentation of the shoulder : we then have 
only to determine the proper position of the child, and also 
that of each shoulder. 

First position of the right shoulder. The general position 
of the child is here the same as in the first position of the 
right haunch, that is, the head corresponds to the left, and 
the feet to the right ; the back of the child looks to the 
pubis, and is directed a little upward, while the anterior 
surfaces have an opposite direction. 

The right hand is introduced in the state of supination, 
and slightly crowds the shoulder backward by acting upon 
the point of support, then glides over the anterior surfaces 
of the child to the feet, which are grasped separately or 
together, to bring them into the cavity, in order to direct 
the heels towards the right cotyloid cavity, and thus to 
terminate the labor by the second position of the feet. 
{See PI. XL VI. Fig. 1.) 

Second position of the right shoulder. Although the gene- 
ral position of the child is the same here as in the preceding, 

15 



122 MIDWIFERY ILLUSTRATED. 

its peculiar situation differs widely. The head, it is true, is 
situated on the right iliac fossa, and the feet correspond to 
the left iliac fossa : but as the back of the child is behind, 
and the anterior surfaces upward, this position and the first 
of the left shoulder, are the most difficult for the manoeuvre, 
as may easily be understood by the following explanation, 
but particularly by looking at the parts. {See PL XLVI. 
Fig. 2.) 

The left hand is introduced in a state of pronation, crowds 
back the trunk of the child, passes in the same position 
over the anterior surfaces to the feet, which must be grasped 
together, pulling most upon the farther foot in. order to 
favor the turning of the child downward, and thus to bring 
it to the first position of the feet, to terminate the labor in 
the same manner. In this manoeuvre the utmost moderation 
must be used. 

First position of the left shoulder. This position differs 
from the preceding only in the situation of the head, which 
is on the left iliac fossa, and in that of the feet, which 
correspond to the right iliac fossa. 

The right hand is required : it is introduced in the state 
of pronation, glides over the anterior surfaces of the child 
to the feet, which must be seized together to bring them 
into the second position of the feet, pulling more particu- 
larly on the right foot, which is the more remote, in order 
to favor the motion of turning downward, and the labor is 
terminated as in the second position of the feet. {See PL 
XL VII Fig. 1.) 

Second position of the left shoulder. This is perfectly 
analogous with the first of the right shoulder as to the 
general position of the child ; as in this latter, in fact, the 
anterior surfaces of the child are downward, which faci- 



MIDWIFERY ILLUSTRATED. 123 

litates the termination of the labor, as may have been 
ascertained in the first position of the right shoulder. 

In the second position of the left shoulder, the child's 
head rests on the right iliac fossa, and the feet correspond 
to the left: its posterior surfaces look upward and a little 
forward, and the anterior surfaces downward and a little 
backward. 

The left hand is introduced in a state of semipronation 
as far as the shoulder, which is crowded back, as is also 
the trunk of the child, rotating it slightly on itself, in order 
to bring the anterior surfaces downward : the hand, placed 
in this position, then glides over these same surfaces from 
right to left to the feet, which are grasped separately or 
together, and brought towards the cotyloid cavity of the 
left side ; the labor terminates as in the first position of the 
feet. (See PL XL VII Fig. 2.) 

Presentation of the shoulder ', complicated ivith the appear- 
ance of the whole or a part of the arm. Among the ancients, 
and even in modern times, when one of the upper limbs 
appeared, or a part or the whole presented out of the vulva, 
all the assistants were affrighted ; the accoucheur was 
terrified, persuaded that the woman could not be delivered 
unless her offspring were mutilated : hence, the limb which 
presented, was twisted or amputated at its articulation with 
the trunk, and the child thus dismembered, was afterwards 
delivered by the feet, and surviving for a longer or shorter 
period, a punishment as cruel as it was useless. 

Practitioners w T ere justly alarmed with the awful conse- 
quences of this manoeuvre, and endeavored to substitute for 
it a process, which, although not so fatal, was not more 
practicable. In fact, what was advised 1 To return the 
extremity which appeared, and then to seek the feet. But 



124 MIDWIFERY ILLUSTRATED. 

when the uterus has contracted powerfully on the child, 
this manoeuvre is useless, and even impossible, and fre- 
quently dangerous ; for the limb generally re-appears at the 
first contraction of the uterus, and these repeated efforts 
must necessarily fatigue and irritate the parts of the female, 
which being swelled and tumefied, may thus impede the 
termination of the labor. What then must be done ? We 
must not return the arm to seek for the feet ; but the 
manoeuvre must be performed as if there was no arm, as if 
the child was a cripple : we must consider the appearance 
of the extremity only as an unfortunate circumstance, which 
in fact renders the termination of the labor complex, but 
does not prevent it : for it is certain, as Deleurye had 
demonstrated, that, as soon as the child goes towards the 
base of the uterus, the arm re-ascends with the body, and 
disappears. 

The following are the principal points to be regarded 
in the manoeuvre where the arm appears : first, when the 
whole or a part of the arm has appeared for a short time, and 
the parts of the mother are neither tumefied nor inflamed, 
we must proceed immediately to terminate the labor, in the 
manner to be mentioned hereafter, when the exact position 
of the child is determined by inspecting the limb which 
presents ; second, but if the arm has been delivered for a 
long time, and the delivery of the child has been attempted 
by drawing it downward, if the parts of the female, irritated 
by this imprudent manoeuvre, are very much inflamed, it is 
to be feared, that the neck contracting powerfully on the 
arm of the child, may very much impede the termination of 
the labor. We must then employ venesection, baths, fumi- 
gations, and all the means which are disposed to soften the 
parts of the female, before proceeding to the manoeuvre; 



MIDWIFERY ILLUSTRATED. 125 

third, if the genital organs are simply tumefied, swelled, but 
not inflamed, we may proceed to the manoeuvre without 
regarding this circumstance ; in this case, a skillful accou- 
cheur can overcome by his address and perseverance the 
disadvantage of its position ; fourth, sometimes the arm of 
the child is not only tumefied and red, but even bruised, 
and the epidermis is detached ; this would lead us to believe 
the child dead, and the arm gangrenous : this opinion is 
often erroneous, as the arm may be partly sphacelated, and 
the child not entirely lifeless ; but the accoucheur should 
terminate the labor as quickly as possible, in order to pay 
that attention to the child which its situation requires ; fifth, 
but if the arm be more or less ecchymosed and sphacelated, 
and appears to be attached to the trunk only by a fold of 
the integuments, in consequence of the violent tractions 
upon it, as the death of the child is then certain, its delivery 
should not be attempted, until the arm is separated from the 
trunk, to prevent this separation from taking place in the 
uterus, and to avoid the blame of an accident committed 
by another ; sixth, finally, if when called upon to terminate 
a difficult labor, the peculiar character of which may not 
be mentioned, you should discover by touching, that it is a 
shoulder presentation, but that the arm is wanting, if you 
have reason to think that it has been removed, you must 
not proceed to the manoeuvre, until the deficiency of the 
arm is mentioned, in order that you may not be accused of 
mutilating the child. In all these different cases, before 
proceeding to the manoeuvre the child must be wet, by 
pouring water on the most apparent part of the arm. 



126 MIDWIFERY ILLUSTRATED. 



OF THE MANOEUVRE, IN CASE OF ANY PRESENTATION OF THE 
SHOULDER, ATTENDED WITH THE APPEARANCE OF THE WHOLE 
OR PART OF THE ARM. 

First position of the right shoulder, the arm appearing. 
After determining the exact situation of the child, which is 
in the first position, by inspecting the presenting arm, a fillet 
is applied to the latter, which is held by an assistant, stand- 
ing on the right of the accoucheur. The right hand is then 
introduced in a state of supination to the axilla of the child, 
and the trunk is pushed back ; the same hand then proceeds 
along the anterior surfaces to the feet, which are seized 
and brought towards the inner part of the right iliac fossa, 
to terminate as in the second position of the feet. When 
this manoeuvre is properly performed, the arm re-enters, 
and even entirely disappears. But when the child is about 
to be delivered, the accoucheur should take hold of the 
fillet upon the arm, and act upon this also, while the trunk 
is passing outward. (See PL XLVIIL Fig. 1.) 

Second position of the right shoulder, the arm presenting. 
We proceed at first in this position as with the preceding ; 
that is, after attaching a fillet to the arm which presents, 
the left hand is introduced in a state of pronation to the 
trunk of the child, which is pushed back gently, in order to 
pass over the anterior surfaces to the feet, which must be 
grasped together, and not separately, being careful to pull 
rather upon the farther one, in order to facilitate the turn- 
ing of the child below, and the labor is terminated as in the 
first position of the feet. (See PL XL VIII. Fig. 2.) 

When the child is turned, we should be careful to pass 



MIDWIFERY ILLUSTRATED. 127 

the fillet from left to right, to preserve the relation of the 
arm with the trunk, which has turned on itself. If this 
should be neglected, the arm would be crossed under the 
trunk, and might perhaps be fractured during the termina- 
tion of labor. 

It may perhaps appear strange, that in treating of the 
manoeuvre in particular, relative to the different presenta- 
tions of the trunk, we have neglected the third and fourth 
positions, generally admitted by all authors since Beaude- 
loque. In fact, this innovation demands some explanation 
on our part. We must then declare that these positions are 
more imaginary than real, and in fact do not exist : those 
practitioners who have admitted them, have never seen 
them ; and the simple relation of the parts prove them to 
be impossible. In fact, we can easily imagine the child to 
be placed across the upper strait, but we cannot imagine 
how it can preserve its position there from before back- 
ward: therefore, why overload the science with useless 
details, and the art with operations which will never be 
performed. Finally, it is time that the science of obstetrics 
should be freed from certain trammels which oppose its 
perfection : for these reasons we have rejected the third 
and fourth positions. Farther, in regard to the termination 
of labors in which any part of the external surfaces of the 
trunk of the child presents, we would observe, that in these 
different presentations, the accoucheur must consider it a 
principle, always to bring the anterior surfaces of the child 
below. The object of this fundamental law is, to place 
the child always in the first or second position of the feet, 
which is the only and the true method of terminating the 
labor. 

Presentation of the head. The manoeuvre of the different 



128 MIDWIFERY ILLUSTRATED. 

presentations of the head, differs from those of the trunk, 
or even of the lower extremities. They are similar in 
appearance, but differ in a manner not to be misunderstood. 
The presentation of the head, for instance, does not in itself 
require a manoeuvre, since, strictly speaking, the labor may 
terminate naturally, whatever part of its external surface 
may present at the brim. Hence it follows, that since the 
general principles which have guided us in stating the 
manoeuvre of the presentations of the trunk or the lower 
extremities, cannot apply to that of the head, the latter 
cannot be explained without considering anew the reasons 
which require its use, and also the mode in which it is 
performed. 

In all presentations of the head, we should doubtless 
attempt to restore it to its natural position, by placing the 
vertex so as to bring it constantly towards the centre of the 
pelvis, by which the labor may afterwards be left to nature. 
But in order that this principle may be strictly true, we 
must suppose the uterus still possesses the power of con- 
traction : and what should we gain by this mode of treat- 
ment in a feeble woman, who appears just expiring, and 
whose life is threatened by severe hemorrhage or horrid 
convulsions 1 Far from losing precious time, we must on 
the contrary hasten to terminate the labor. 

Thus, whatever may be the situation of the head at the 
brim, and when its unfavorable position completely prevents 
the termination of the labor, a skillful and prudent accou- 
cheur should attempt every known means of bringing the 
occiput to the centre of the pelvis, should solicit contraction 
of the uterus, and then leave the termination of the labor to 
nature. But if this manoeuvre cannot be executed, if the 
head, propelled by severe contractions of the uterus, tends 




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MIDWIFERY ILLUSTRATED. 129 

more and more to an unfavorable position, we must not 
hesitate: the head must then be pushed back, and be placed 
on one of the iliac fossse ; we must bring down the feet, and 
terminate the labor as we have mentioned when speaking 
of the feet presentation. 

The same course must be pursued when severe and 
alarming symptoms imminently threaten the lives of the 
mother and child. Here we must not depend upon the 
resources of nature, and even if the occiput presents, the 
same course must be followed as in the preceding case. 

The manoeuvre relative to the different positions of the 
head is remarkable in this respect, that the same or nearly 
the same manual operation is required : thus, whatever 
may be the position of the head at the brim, we must 
always direct the occipital portion towards one of the iliac 
fossse, and then carry the hand along the anterior surfaces 
to the feet, which are brought into the cavity, thus turning 
the child on itself, to terminate by the manoeuvre of the feet. 

We have distinguished five presentations of the head, viz : 
first, the vertex, or sinciput; second, the occiput, or the 
summit ; third, the face ; fourth and fifth, the temples or 
the auricular regions. 

A. Presentation of the vertex, or sinciput. When the 
vertex or sinciput presents at the brim, it may be recog- 
nized by the presence of a broad, rounded, hard tumor, in 
which, at an interval of three fingers' breadth, the two 
fontanelles, the known form of which and direction, as also 
the sutures and their direction, present the practitioner with 
the modes of determining the peculiar position of the head. 

We must remark, here, that in every presentation of the 

head, the body of the child is as it were folded on itself, and 

thus is bent in the most natural position. 
10 



130 MIDWIFERY ILLUSTRATED. 

First position of the vertex. In this position, the sinciput 
occupies the whole superior strait; the occiput is to the 
left, and the face to the right. 

The left hand is introduced, and pushes back the head, 
which is raised with the ends of the fingers, and placed on 
the left iliac fossa. The hand then glides over its anterior 
surfaces, directing the fingers successively on the left side 
of the child, the shoulder, the groin, to arrive at the feet, 
carries them together or separately into the vagina, and 
thus the labor terminates like the second position of the feet. 

If, in this manoeuvre, as well as in all those which involve 
the different presentations of the head, the latter is situated 
too near to the orifice, and consequently to the brim, and 
should impede the disengagement of the feet too much, 
we must first attempt to push it back with the palm of the 
hand which is introduced already, or with the fingers of the 
other hand, which should be carried as high as the head. 
If this first mode is not sufficient, and if the head, wedged 
as it were in a part of the strait, presents an almost invin- 
cible resistance to the extraction of the feet, we must then 
use an instrument termed a repoussoir. The mode of using 
it is as follows. 

A fillet is first applied on one or both of the child's feet : 
we then introduce to the child's head the instrument men- 
tioned, pull strongly on the feet and carry them outward, 
while we push the head inward, turn the child without 
difficulty, and terminate the labor, which would otherwise 
present difficulties sometimes insurmountable. (See PL 
XLIX. and L. Fig. 1 and 2.) 

This course should be adopted in all presentations of the 
head generally, where it is really difficult to disengage the 
feet, or as is commonly said, to turn the child. 



MIDWIFERY ILLUSTRATED. 131 

Second position of the vertex. The child is situated as in 
the preceding position ; the occiput, however, is to the right 
and forward, and the face to the left and backward. 

The right hand is introduced and carried to the left side 
of the pelvis, to push the head towards the right iliac fossa. 
The fingers are then passed towards the left side of the 
child's head, the shoulder, and the haunch to the feet, 
which are seized together or separately, brought into the 
cavity, and the labor is terminated as in the first position 
of the feet. 

Third position of the vertex. In this position, the occiput 
looks toward the right iliac fossa, and the face to the left 
cotyloid cavity. 

In this case the manoeuvre is executed with the right 
hand, which is introduced to the head, embraces it, carries 
it on the right iliac fossa, proceeds along the anterior sur- 
faces to the feet, which it brings into the cavity, and it is 
terminated as in the first position of the feet. 

Fourth position of the vertex. Here the occiput looks to 
the left sacro-iliac symphysis, and the face to the right 
cotyloid cavity. 

The left hand is introduced, and carried, as in the pre- 
ceding positions, along the anterior surfaces to the feet, 
which are brought behind the cotyloid cavity of the right 
side, and the labor terminates in the second position of 
the feet. 

B. Presentation of the occiput. This presentation, which 
is essentially natural, requires manual assistance only when 
serious symptoms frustrate the exertions of nature, and 
endanger the life of the mother and child. The situation 
of the head at the upper strait is the same as in the most 



132 MIDWIFERY ILLUSTRATED. 

natural labor, and therefore we shall omit repeating i for 
the four positions of the head. 

The characters which mark the presentation of the 
occiput cannot be mistaken, when the hairy scalp is not 
tumefied, and the sutures, and especially the fontanelles, are 
as it were exposed. But this is not the case when the head 
has been engaged for a long time, and is closely embraced 
in the strait, and is therefore more or less swelled, and thus 
conceals the occiput from the researches of the index 
finger, for it is then almost impossible to discern it through 
the very large swelling which covers it. Hence the pre- 
sentation of the occiput may be determined by negative 
signs ; by the absence of the marks which characterize the 
other presentations of the head. 

First position of the occiput. The left hand is introduced, 
and raises the head to carry it on the left iliac fossa ; the 
feet are then sought for, and the labor is terminated as in 
the second position of the feet. 

Second position of the occiput. In this case, the manual 
is executed by the right hand, as in the second position of 
the vertex, to terminate as in the first position of the feet. 

Third position of the occiput. The right hand pushes the 
head upon the right iliac fossa, and grasps the feet to 
terminate the labor as in the first position of the feet. 

Fourth position of the occiput. . As in the fourth position 
of the vertex, the left hand seeks the feet, to terminate the 
labor as in the second position of the feet. 

D. Presentation of the face. The most certain and most 
palpable characters commonly mark this region, viz., the 
nose, the mouth, the edges of the orbits, &c. If any pre- 
sentation of the head requires the employment of all possible 
means to restore it to its natural position, it is undoubtedly 



MIDWIFERY ILLUSTRATED. 133 

this. The forced situation of the child, the danger which 
threatens it, the impossibility of passing fortunately through 
the straits of the pelvis in its present situation, oblige us 
to raise the chin on the chest, to place it more properly, or 
to seek the feet immediately. The first process is un- 
doubtedly preferable, because if the head is once in a pro- 
per position, the rest of the labor may easily be performed 
by the resources of nature alone. But if this cannot be 
accomplished, the child must be turned, and the feet brought 
down. 

First position of the face. The head is placed so that the 
forehead, not the occiput, corresponds to the left, and the 
chin to the right. In this position, the left hand must be 
introduced towards the right side of the uterus, push the 
head upon the left iliac fossa, correcting as much as possible 
the forced and unfavorable situation of the child's head : we 
then glide the hand along the anterior surfaces to the feet, 
which are carried towards the right side of the pelvis, and 
the labor is terminated as in the second position of the feet. 

Second position of the face. The situation of the head is 
the opposite of the preceding : as for the rest, the same 
indication is to be performed with the right hand. 

Third position of the face. Here the forehead corresponds 
to the right sacro-iliac symphysis, and the chin to the left 
cotyloid cavity. In this position, the right hand is intro- 
duced, and the head is carried by it on the iliac fossa of the 
same side ; the feet are brought down to terminate as in 
the first position of the feet. 

Fourth position of the face. Here the forehead corres- 
ponds to the left sacro-iliac symphysis, and the chin to the 
right cotyloid cavity. The left hand being introduced, 



134 MIDWIFERY ILLUSTRATED. 

places the head on the left iliac fossa, and terminates as in 
the second position of the feet. (See PL LI. Fig. 1 and 2.) 

Before proceeding to the last of the presentations of the 
head, we must remark, that the first and second positions 
of the face are the most favorable to apply the lever, which 
is introduced immediately on the left, or the right side of 
the pelvis, according to the peculiar position of the head ; 
this instrument being placed directly on the occiput, tends 
to bring it, as well as the whole head, into the cavity of 
the pelvis. 

F. Presentation of the auricular region, or of the sides of the 
head. The marks common to the two sides of the head 
are, a hard and rounded tumor, indicating this last part. 
The presence of the ear, and of the angle of the lower jaw, 
leave no doubt in regard to the peculiar position of each ear. 

First "position. Right side. According to our mode of 
classifying the different positions of the sides of the head, 
the vertex, in this first position, is considered as correspond- 
ing to the base of the left iliac fossa, the face to the sacrum, 
the posterior or loose edge of the ear to the pubis. The 
right hand raises the head, carries it on the right iliac fossa, 
to terminate the labor in the first position of the feet. 

First position. Left side. The general position of the 
head, relative to the superior strait, is the same as in the 
preceding position. Here, however, the face corresponds to 
the pubis, and the posterior edge of the ear to the sacrum. 
The right hand is introduced, raises the head and carries it 
toward the right iliac fossa: the feet are then brought 
down, and the labor is terminated as in the preceding 
position. 

Second position. Right side. The top of the head looks 
to the base of the right iliac fossa, and the face to the pubis. 



MIDWIFERY ILLUSTRATED. 135 

The left hand is directed towards the occiput, to place it 
on the left iliac fossa, and goes along the left side of the 
child to the feet, and the labor is terminated as in the 
second position of the feet. 

Second position. Left side. The face corresponds to the 
sacrum ; otherwise, the child is as in the first position. 
The left hand will place the occiput on the left iliac fossa, 
to terminate the labor as in the second position of the feet. 

Third position. Bight side. The top of the head corres- 
ponds to the pubis, and the face to the left side of the pelvis. 
The right hand being introduced on the left side of the 
pelvis, embraces the head, and carries it on the right iliac 
fossa. The feet are then brought down, and the labor 
terminated in the first position. 

Third position. Left side. The child's face looks to the 
right side of the pelvis, and the summit to the pubis. The 
left hand is introduced to the right side of the pelvis, dis- 
places the head, pushes it towards the left iliac fossa, 
brings down the feet, and terminates as in the second 
position of the feet. 

Fourth position. Right side. The top of the head looks 
to the sacrum, and the face to the right side of the pelvis. 
The left hand will push back the head, and carry it towards 
the left iliac fossa, to terminate the labor as in the second 
position of the feet. 

Fourth position. Left side. The top of the head looks 
to the sacrum, and the face to the left side of the pelvis. 
The right hand is directed towards the left side of the 
pelvis, raises the head and carries it towards the right iliac 
fossa, and terminates as in the first position of the feet. 
(See PL LIT. Fig. 1 and 2.) 



130 MIDWIFERY ILLUSTRATED. 

We conclude our remarks in regard to the simple ma- 
noeuvre, which requires no instrument, and can be executed 
solely by the hand; but the head particularly, sometimes 
requires a more complex manoeuvre. In fact, the head is 
not unfrequently so wedged in the strait, that it can neither 
be pushed back into the uterus, nor brought into the cavity 
without the aid of instruments : hence, the history of the 
complex or instrumental manoeuvre naturally follows. 



COMPLEX OR INSTRUMENTAL MANOEUVRE. 

When the hand only is required to terminate the labor, 
the operation is termed the simple manoeuvre : it is com- 
pound, or even complex, when the accoucheur is obliged 
to use instruments. Some of these instruments are simply 
auxiliaries to the hand, and neither injure the parts of the 
mother, nor those of the child : although they are few, their 
services to the art, and consequently to humanity, are in- 
valuable. These instruments are the forceps, the lever, 
the blunt-hook, and the fillet. The simple instrumental 
manoeuvre is performed with them. 

The others are more dangerous in their application, and 
injure in a greater or less degree the parts of the mother, 
or those of the child. These instruments are, first, those 
employed in performing the Cesarean operation and sym- 
physiotomy ; second, all those which are used in extracting 
the dead child. {For a description of these instruments, see 
the latter end of the book.) 

Use of the forceps. The forceps is applied only to the 
head of the child. The form of the instrument, and the 
mechanism of its application, indicate very plainly the 



PI..LXVJ. 




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of dropsy. 




in. hydro r€/7^<t/.'/s. 



Jrirfeco den' 



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JPX.lDLVlll. 



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MIDWIFERY ILLUSTRATED. 137 

danger of seizing any other part of the child with it. The 
causes which require the application of the forceps, are 
doubtless very numerous ; they may, however, be reduced 
to the following, some of which depend on the mother, 
others on the child. The first proceed partly from the re- 
sistance of the external genital organs, and partly from the 
greater or less degree of narrowness of the upper or lower 
strait. The second may generally be ascribed to the big- 
ness of the child's head, and also to the inactivity of the 
uterus. The forceps may be used on the child's head when 
it has descended into the cavity, or is retained at the supe- 
rior strait, whether the trunk is still within the uterus, or 
has emerged from the external organs of generation. It 
must be applied only on the sides of the child's head : this 
precept admits of but one exception, which we shall care- 
fully mention. 

A. Application of the forceps on the head in the cavity, the 
trunk being in the uterus. When the head has descended 
into the cavity, it may have four different positions. In the 
first case, the occiput looks towards the pubis, and the face 
to the sacrum ; in the second case, the opposite is true ; in 
the third, the occiput is to the left, and the face to the 
right ; in the fourth, it has an opposite position. 

Case first. The occiput upward, the face downward. The 
female being placed properly, and as if for the simple ma- 
noeuvre, the operator takes with the left hand the male 
branch of the forceps or that with the pivot, which must 
previously be soaked in warm water, and oiled : the right 
hand, which is also greased, is introduced into the genital 
organs on the left side, so as to place two or three fingers 
between the neck of the uterus and the head of the child. 
These precautions being taken, we glide along them the 

17 



133 MIDWIFERY ILLUSTRATED. 

male blade, which is held by the left hand, and conducted 
so as to describe a long curve, carrying the extremity just 
introduced from before backward and from above down- 
ward, which cannot be done unless the handle of the blade 
is at first elevated outward, then depressed as much, and 
almost perpendicularly between the thighs of the female. 
(See PL LIU. Fig. 1.) By this means the blade will be 
placed flat first on a part of the forehead, and then applied 
on the left lateral region of the child. 

The male blade being thus applied, and kept in place 
firmly by an assistant, the operator will withdraw the right 
hand, to grasp the female or mortised blade, and by the aid 
of the fingers of the left hand, interposed in turn between 
the inner edge of the right side of the uterus, and the cor- 
responding surface of the head, he will place this second 
blade like the first. 

When the forceps is properly applied, the two blades 
should be introduced about four or five inches, and the 
pivot of the male blade at the height and in the direction of 
the symphysis pubis (See PL LIU. Fig. 2.) ; the two blades 
are crossed on the outside, and united by their pivot on 
which the key acts ; the instrument is closed at first with 
a moderate degree of force, and afterwards more strongly, 
so that the extremities of the blades shall touch. The 
blades being thus in contact, their handles are confined 
with a ribbon, or with the corner of a towel. The ope- 
rator, after seizing the instrument with the left hand placed 
in a state of supination near the vulva, and the right hand 
in pronation towards its opposite extremity, will pull upon 
the head at first moderately, and then a little more power- 
fully, to bring it outward, carrying the instrument first to 
the right, then to the left, and gradually depressing it to 



MIDWIFERY ILLUSTRATED. 139 

bring the occiput under the arch of the pubis. The instru- 
ment is now raised, the face and the forehead are turned in 
the cavity of the sacrum, which often distends the perineum 
very much, and requires the operator to support it strongly 
with the left hand, while the right will continue to extract 
the head, gradually raising the body and the blades of the 
forceps towards the belly of the mother, which will cause 
the occiput to turn under the arch of the pubis, and will 
finally deliver it with the rest of the head out of the vulva. 

Case second. The occiput downivard, and the face upward. 
Although the situation of the head in this second case is 
the opposite of the preceding, the forceps, however, are 
applied in the same manner ; that is, the two blades must 
be introduced and placed precisely as in the first case : the 
head, however, must be extracted more slowly, because 
the face forced, like the occiput in the preceding case, to 
turn under the arch of the pubis, does not perform this 
motion as well as the latter, on account of its prominences 
and irregularities. 

From this arrangement it follows that the perineum is 
still more prominent here than in the preceding case, on 
account of the rounded and very projecting form of the 
occiput. 

Case third. The occiput to the right or left, and the face 
to the opposite side. Perhaps the head, in descending into 
the cavity, does not rotate sufficiently to be properly situated 
in the perineal strait, and it then remains placed on the 
side, and wedged in between the two tuberosities of the 
ischium. 

It has been thought that when in this position, the forceps 
was the only remedy : but the mode of applying it in this 
case differs much from that in the two preceding cases. 



140 MIDWIFERY ILLUSTRATED. 

Thus supposing that the occiput was to the right and the 
face to the left, the female blade is seized with the right 
hand, keeping it flat on the abdomen of the mother, and in 
the direction of the symphysis pubis, to place it directly in 
the hollow of the sacrum. In proportion as the blade is 
introduced, its extremity is directed a little towards the 
posterior regions of the child's head, and it is kept in that 
position by an assistant : the male blade is then taken and 
introduced in the same manner under the symphysis pubis, 
in order to place it on the opposite side of the child's head, 
and then the pivot is fitted to the mortise of the female 
blade. The two blades being tied and kept firmly together, 
the operator, still retaining his hold on the forceps, will 
stand on the outside of the left thigh of the mother, in 
order to perform with the instrument a very extensive cir- 
cular motion, which places the occiput under the arch of 
the pubis, while the face looks towards the hollow of the 
sacrum. The labor is terminated as in the preceding case. 

Note. In this violent rotation of the head on its axis, it 
is exposed to be twisted if we act too quickly, because the 
trunk does not always follow the motions of the child's 
head : the skillful operator will foresee, by the resistance 
he meets with, the dangers to which the child is exposed, 
and he will act accordingly. 

Case fourth. The occiput in the opposite direction. In this 
unfavorable position of the child's head, the blades must be 
used as in the preceding case, with this difference, however, 
that the female blade, which must be applied first, should 
be introduced under the arch of the pubis, and the male 
blade, near the hollow of the sacrum. Farther, the long 
circular motion of the head must be executed as in the 
preceding case, with this difference, however, that the 



MIDWIFERY ILLUSTRATED. 141 

operator, in performing it, stands on the outside of the right 
thigh of the mother. 

B. Application of the forceps on the head at the superior 
strait, the child being in the uterus. The head may be 
arrested at the superior strait, either by the narrowness of 
this opening, or by the unusual size of the child's head : 
in both cases there is generally inactivity of the uterus. 
The application of the forceps is imperiously demanded in 
these cases, but it should not be used except when the 
superior strait measures not less than from three to three 
and a quarter inches from before backward, and the pelvis 
also must not be too evidently deformed. 

The head, when arrested at the superior strait, may be 
placed there in four different ways, as in the cavity, although 
with some modifications to be mentioned hereafter. 

In the first and second case, we suppose the head placed 

longitudinally in the direction of the sacro-pubic diameter, 

with the occiput looking sometimes to the pubis, sometimes 

to the sacrum. In these first two cases, the forceps must be 

applied as before, that is, the male blade is grasped with the 

left hand, and the female with the right; they must be 

introduced successively, and applied on the sides of the 

child's head, after placing one hand in the vagina to direct 

the progress of the instrument. But, considering the great 

distance of the head, the instrument must be carried much 

more deeply : without this precaution, its extremity alone 

will be placed on the head, and upon the least effort the 

instrument will doubtless slip, and by coming out too 

quickly would necessarily be liable to expose the parts of 

the mother to contusions and even to lacerations of greater 

or less extent. 

When the instrument is properly and methodically 



142 MIDWIFERY ILLUSTRATED. 

applied, we endeavor to bring the head into the cavity, 
taking care to pull in the direction of the superior strait, 
and in such a manner that the great diameters of the head 
are as much as possible in relation with those of the pelvis. 

As in the case now treated of, the external organs of 
generation are not dilated : and as they preserve their natu- 
ral resistance, it is very important to pull upon the head just 
when it is about to escape, sustaining the external organs 
with the utmost care. 

When the pelvis is extremely narrow, the head may 
present on the side, and propelled by violent and continued 
pains, it may be wedged in between the sacro-vertebral 
prominence on one side, and the symphysis pubis on the 
other. In this critical situation the child will inevitably 
perish, if it be not speedily delivered with the forceps ; but 
as the head is immovable, and as it is impossible to apply 
the blades of the forceps on its sides, since the parietal 
protuberances are firmly compressed between the sacrum 
and the symphysis pubis, the only mode of extracting the 
head is, to seize it longitudinally, that is, from the face to 
the occiput, although these uneven parts are very unfavor- 
able by the application of the blades of the forceps, and 
particularly by keeping them in place. Notwithstanding 
this inconvenience, when the head is once grasped, the 
necessary attempts are made to bring it into the cavity, 
taking every precaution not to crush the face or break the 
bones of the skull. 

As soon as the head has descended into the cavity, we 
immediately withdraw the blades successively, in order to 
introduce them again on the sides of the head, as we have 
mentioned above, and proceed to the final delivery of the 
child in the same manner. 



MIDWIFERY ILLUSTRATED. 143 

C. Application of the forceps on the head, when retained 
at the superior strait, or even in the cavity ', the trunk being 
delivered. Experience has proved that in almost every case 
of delivery by the feet, the child's life is very much endan- 
gered, in consequence of the exertions we are often obliged 
to make on the head to bring it into the cavity, or even to 
disengage it from the external organs of generation. These 
considerations have for some time determined practitioners 
to prefer in these cases the application of the forceps to 
manual delivery. 

As in the simple manoeuvre, the child is always brought 
with the anterior surfaces downward, the forceps are 
applied in the following manner : the body and the arms 
of the child are held, and raised towards the abdomen of 
the mother, and the male blade is introduced on the left 
side of this latter, and placed on the right side of the child's 
head. This blade being held by an assistant, the female 
blade is introduced in like manner on the opposite side. 
The two blades are brought together and secured; the 
trunk of the child is then depressed, previously covering the 
forceps with a towel ; the operator then grasps the child 
and the instrument, acts successively upon each, and brings 
them both from the genital organs. 

In the opposite position, that is, when the face is turned 
towards the pubis and the occiput to the sacrum, the in- 
strument is applied in the same manner as in the preceding 
case ; but here the child is depressed towards the perineum 
instead of being raised towards the abdomen of the mother; 
hence it follows, that the mode of delivery differs slightly, 
although the labor is terminated in about the same manner 
as the preceding. 



144 MIDWIFERY ILLUSTRATED. 



COMPLEX INSTRUMENTAL MANCEUVRE. 

Symphysiotomy, or the operation of dividing the symphy- 
sis pubis, hysterotomy, or the Cesarean operation, and all 
the operations performed on the dead child, compose the 
complex instrumental manoeuvre. In fact, the instruments 
used for these different operations, are more or less detri- 
mental to the mother and child ; with this difference, how- 
ever, that in the first two cases, we have to act upon a 
living child, and that in the latter the child is dead, and the 
instruments are used upon it. In this latter case, it is not 
a labor which must be terminated more or less methodi- 
cally, it is a foreign body from which the mother must be 
relieved. 

The practitioner must conclude to perform the Cesarean 
operation and that of symphysiotomy, neither by the anti- 
quity of the operation, nor by the degree of risk to which 
the mother and child are exposed, but by the narrowness of 
the pelvis : for if it be true that symphysiotomy appears at 
first view less dangerous to the mother than the Cesarean 
operation, it undeniably requires more time, and is much 
more difficult to perform than this latter. 

They are performed in the following manner. 

Symphysiotomy. When the pelvis measures less than 
three inches from before backward, the labor cannot be 
terminated with the forceps. We must employ other 
means : two operations may be performed when the child 
is living, symphysiotomy and hysterotomy. The first of 
these two operations is proper, when the antero-posterior 
diameter measures not less than two inches, for when the 



PL. LXXI 




over the 0* tincce 




an ihe edcre.s of the (M tirvcc 



Ikssie del. 



LiihogJ 'tf ' D. 0. Johnson 



1 



Fig.i 



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Delivery of c 



Delivery ofa,n 



Jassic del . 



/sltfo. jf£Q-.lAn.- 



PLJXHIL. 




orce&t 





Crolchel Forceps. 




Lev&r. 



TL.LKXJV. 





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\t i - nm ii m 



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PL.LSXV. 




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Symphysis Tcnifc. JBirtoUsrietf. 



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MIDWIFERY ILLUSTRATED. 145 

pelvis is less, it cannot, with its small proportions, be suffi- 
ciently separated for the head to pass, without serious 
injury to the mother. 

It is not then sufficient, where the antero-posterior 
diameter is very narrow, to decide upon one of these two 
operations ; we must not employ them without a certainty 
of success, founded on the known dimensions of the head, 
and its relations with the diameters of the pelvis. Hence 
why the Cesarean operation should not be practised, except 
when the narrowness of the pelvis does not admit of sym- 
physiotomy. 

The object of this last operation is to enlarge the pelvis 
generally, and particularly the superior strait. These 
results can be obtained only by dividing in its whole 
length the fibro-cartilage between the two ossa pubis, 
and afterwards by separating them as much as is thought 
necessary, to allow T the head to pass freely through the 
pelvis. 

The practitioner must take into view all these conside- 
rations, before performing either of these two operations. 

In both cases, the first thing is to place the female in a 
proper position : in symphysiotomy, she must lie on the 
edge of the bed, her legs flexed and separated, with the 
pelvis slightly elevated. Two assistants, standing on the 
right and left, support the legs and separate them very 
much, when the inter-pubic cartilage is divided : two other 
assistants are also in attendance, either to separate the lips 
of the external incision, or to assist in separating the thighs. 

The mons veneris must be shaved, and the bladder must 
be emptied by a catheter, which must remain there, in 
order to carry the urethra to the right or left during the 
operation, and to prevent it from being wounded. 

18 



146 MIDWIFERY ILLUSTRATED. 

The operator stands between the legs of the female, with 
a common bistoury in his right hand, and at two or three 
incisions divides the skin and cellular tissue, carrying the 
instrument in the direction of the symphysis pubis. The 
fibro-cartilage being exposed, he then uses the symphysis 
knife, with which the symphysis is divided, taking care not 
to hurry, and supporting the instrument firmly on the fibro- 
cartilage. (See PL L VII. Fig. 1.) 

In proportion as the fibro-cartilage is divided, the thighs 
of the female are separated, in order to facilitate the rest of 
the operation ; but the last strokes of the bistoury should 
be made with care, for fear of wounding the bladder. 
Perhaps it would be better to divide the last layers of the 
fibro-cartilage, by separating the thighs, rather than with 
the knife. 

The operator must direct and order the necessary 
degree of separation, which should be made slowly, gra- 
dually and constantly. When the requisite degree of 
separation is attained, the practitioner must terminate the 
labor immediately, either by bringing down the feet, if he 
thinks proper, or by applying the forceps to the head. If 
this latter seems to be engaged easily, the labor may be left 
to the contractions of the uterus. 

But in this operation, the labor rarely terminates sponta- 
neously, and it would even be dangerous to leave it to 
nature alone : it is infinitely more prudent for the mother 
and child, to deliver as promptly as possible, in the manner 
mentioned above. 

The labor being terminated, we must instantly bring the 
thighs together, put the separated ossa pubis in contact, 
and attend to the dressing, which is performed by applying 
straps of adhesive plaster, in order that the parts may heal 



MIDWIFERY ILLUSTRATED. 147 

by the first intention, if possible. The whole is sustained 
by a bandage applied methodically, and sufficiently tight 
to keep the parts directly in contact, and as it were 
immovable. 

The delivery of the placenta, in symphysiotomy, does not 
differ from that generally practised in the most common 
cases of natural labor, when no bad symptoms present. 
Thus the thighs being approximated directly after the ope- 
ration, w r e wait until the contraction of the uterus allows 
us to attend to the delivery of the placenta, which must be 
performed with unusual care, on account of the suffering 
state of the female. She must remain perfectly still for a 
very long time, and not attempt to move until the divided 
parts are perfectly cicatrized. 

Such is a brief description of symphysiotomy : we shall 
now present a few remarks on the operation. 

Authors generally admit that as soon as the fibro-cartilage 
is divided, the divided parts separate spontaneously to a 
greater or less extent, which effect results from the peculiar 
action of the bones, which tend, say they, to separate 
quickly when they are not in contact. This is an error 
which is demonstrated both by anatomical knowledge, and 
by practical facts ; to be satisfied of which, we have merely 
to divide the symphysis pubis in a female cadaver whose 
thighs are simply separated : there will not merely be no 
spontaneous separation, but if the instrument with which 
the section was made be left to itself, it will remain in the 
divided parts, from the contraction caused by the fibro- 
cartilage, the swelling of which is then very manifest. 

If a separation, falsely termed spontaneous, sometimes 
occurs when the fibro-cartilage is divided, it must be 
ascribed to the pulling of the assistants, and not to a special 



148 MIDWIFERY ILLUSTRATED. 

action of the bones of the pelvis, an action inconsistent 
with reason, and unsanctioned by the peculiar laws of the 
motions of the bones of the pelvis. 

When it is determined to perform the operation of sym- 
physiotomy, we must not be content to arrange every thing 
for its success, we must also calculate beforehand to what 
extent the bones of the pubis must be separated to permit 
the head to pass freely. Now we know that one inch of 
separation enlarges the sacro-pubic diameter about two 
lines ; and two inches, four lines, &c. : but the separation 
must never be more than two inches, and it must be remem- 
bered, that with this degree of separation, one part of the 
head is engaged across, which increases in a relative degree 
the sacro-pubic diameter. (See PL LVIII. Fig. 1) 

We cannot, however, be too attentive to the fact that the 
increase of two lines for every inch of separation does not 
occur in every pelvis ; in fact, it takes place only in those 
which, although malformed from before backward, are 
rounded and well-formed forward. The difference in this 
respect is very great in a pelvis in which the symphysis is 
flattened and all the anterior part is nearly even. 

In the first case, in fact, the bones, in separating, always 
proceed more and more forward, and in the second, on the 
contrary, they are only removed to the right and left, with- 
out sensibly increasing the extent of the sacro-pubic 
diameter. (See PL LX. Fig. 1 arid 2.) 

In performing symphysiotomy, the division of the fibro- 
cartilage is not always the most difficult part of the opera- 
tion. The practitioner is more frequently embarrassed by 
the manner in which the labor terminates : we proceed to 
lay down a few general principles on this subject. 

After dividing the inter-pubic fibro-cartilage, when the 



MIDWIFERY ILLUSTRATED. 149 

head is loosely engaged within the pelvis, and every thing 
indicates a prompt and easy delivery, its termination must 
be favored by all possible means, by preserving the degree 
of separation necessary for the head to pass, and encouraging 
the female to sustain her pains, and to bear down : but if 
we suspect the labor will terminate slowly, either from the 
size of the head, the feebleness of the contractions of the 
uterus, or from the want of courage in the mother, it is bet- 
ter to bring down the feet or apply the forceps, if the child's 
head be too closely engaged to think of turning. When it 
is decided to bring down the feet, and to turn the child as it 
is commonly called, we must not extract the head by the 
simple manoeuvre; to attempt it, would be imprudent, on 
account of the difficulty and danger in keeping the bones 
separated long enough to bring the head into the cavity by 
the hands alone. It is better in this case to use the forceps, 
applying them as soon as the head has come to the strait. 
(See PL LIX. Fig. 2.) 

It is important to the success of the operation, and to the 
prevention of bad consequences to the female, to take 
peculiar care of her first attempts at motion. It is very 
difficult to fix the exact period when she can begin to 
walk : that depends much on the good state of the parts, 
the cicatrization of the external wound, and the perfect 
union of the fibro-cartilage. In all these cases, it is better 
for the female to be confined to her bed a little longer, than 
to expose herself to accidents by getting up too soon. 

Finally, when there is no further cause for fear, we begin 
by placing the woman on her knees, supporting her under 
the arms. The next day, or a few days afterwards, she can 
put her feet to the ground, but she should not attempt to 
walk, and she should still be supported as before. In this 



150 MIDWIFERY ILLUSTRATED. 

manner, we may form some opinion of the degree of solidity 
in the parts, and supposing it to be perfect, she may then 
attempt to take a few steps. She should commence draw- 
ing one foot after another, and she must not walk as usual, 
until she is able to stand firmly. 

But there is still a difference between walking in the 
chamber and in the street. In the former, in fact, the alter- 
nate motions of the legs are made without any shaking ; 
in the last, on the contrary, the progression is uneven, and 
one is not always able to conquer its inconveniences : for 
this reason, the female must not leave her apartment, until 
she has long been accustomed to walking in her chamber, 
although it may be very difficult, whatever may be the pre- 
cautions taken to avoid a little limping, and even an incon- 
tinence of urine, which are however but trifling incon- 
veniences for so serious an operation. 

Hysterotomy, or the Cesarean Operation. Among the 
modes employed for terminating unnatural labors, the Cesa- 
rean operation, which is now to be described, holds a separate 
place. We do not allude to the dangers of the operation, 
as symphysiotomy may sometimes be as serious ; we wish 
to be understood only that as a mode of termination, the 
Cesarean operation totally differs from the other resources 
of the art, since it cannot be used except where the fetus 
cannot be born through the pelvis. 

Like all other severe operations, like all extreme means, 
the Cesarean operation has experienced many vicissitudes. 
At one time employed without measure, then abandoned 
and even proscribed on account of its dangers, it is now 
considered in its proper light, as a violent, and doubtless a 
very dangerous operation, but as the last and only resource 
of art to save the lives of mother and child. Employed with 



MIDWIFERY ILLUSTRATED. 151 

discernment, and when the female can support its formi- 
dable dangers, it may be perfectly successful, and then 
becomes the most brilliant triumph of art over powerless 
nature. 

This operation should be practised only when the antero- 
posterior diameter of the pelvis is less than two and a half 
inches, which measurement is very rare, and should give 
confidence to those who are terrified at this operation ; but 
since it is asserted that in cases of the Cesarean operation, 
the child cannot be delivered through the pelvis, some other 
passage must be provided for it. This end can be attained 
in three modes : the process of the ancients, that of Beau- 
deloque, and that of Lauvergeat. 

Of these three processes, the first is that most generally 
employed, and yet it is not the least inconvenient, as we 
shall show hereafter. Let us first describe the operation. 

The female being placed on the edge of her bed, and 
slightly inclined towards the side opposite the operator, the 
latter holding a common bistoury with a spring blade, 
makes a longitudinal incision from seven to eight inches in 
length, in the direction of the rectus muscle, and one inch 
from its outer edge, so that the lower angle of the wound 
is three or four fingers' breadth above the pubic region. 
This precaution is necessary in order that the instrument 
in its progress may not wound the membranous part of the 
abdominal muscles. 

As soon as the integuments are divided, some portions of 
the intestine may project through the external wound; 
they must immediately be very carefully replaced, since if 
injured severe symptoms may follow. In order to avoid 
this accident, it has been recommended to introduce a probe- 
pointed bistoury, in one or the other direction, raising the 



152 MIDWIFERY ILLUSTRATED. 

integuments with the instrument, the blade of which is 
then directed from within outward. 

When the integuments are divided and the edges of the 
wound are slightly separated, the body of the uterus ap- 
pears, which can be recognized by its globular form, and its 
shining and glistening appearance. We must instantly open 
it by an incision from above downward, in the direction of 
that of the integuments, and four fingers' breadth in extent, 
large enough, of course, to extract the child. This incision 
should be made so that its lower angle comes at or near 
the centre of the incision in the integuments. (See PL 
LXI. Fig. 1.) The operator then introduces one hand 
within the uterus, seeks for the child's feet, which he grasps 
and delivers with celerity and prudence. (See PL LXIL) 
Although the child is extracted through the soft parts, 
which oppose its delivery but slightly, it is not strictly 
necessary to proceed as methodically and with the same 
precautions as when the labor is terminated in the usual 
manner. Much caution however must be used. We must 
always remember that this severe operation has been per- 
formed to save the child, and that, with all our care, its 
life is endangered by weakness. 

After the child is delivered, the thing most important to 
the success of the operation is the delivery of the placenta, 
which may be accomplished in two modes ; either through 
the incision, or through the natural passages. The first 
mode demands no directions : in fact, we have only to re- 
move the placenta through the external wound, by the aid 
of the cord, and to deliver it without any other precaution 
than that required by its passage through the wound in the 
uterus. But to obtain this result, the placenta must be 
completely detached after the delivery of the child : for if 



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MIDWIFERY ILLUSTRATED. 153 

the least force is required, it is infinitely better to leave it 
within the uterus, and to wait until the uterine contrac- 
tions bring it down towards the neck, and to extract from 
the natural passages. This last process is highly advanta- 
geous, as it favors the flow of the fluids towards the vagina, 
and thus turns them from the wound in the uterus, through 
which it is always dangerous for them to pass. 

But if the umbilical cord be left in the uterus after the 
child is delivered, it can pass through the neck but rarely, 
and as in this case we must wait until the whole placenta 
has come there, before we can deliver it, it is recommended 
immediately after the child is expelled, and the cord 
divided, to introduce its cut extremity into the tube of a 
long gum-elastic sound, the opposite extremity of which is 
directed through the wound in the uterus, towards the inner 
opening of the os tincae : in this manner, the cord is brought 
through the vagina out of the external organs of generation, 
and then the placenta can be extracted. 

Although this mode is ingenious, something was still de- 
sirable, since the cord not being attached to the tube of the 
sound, might easily escape and frustrate this part of the 
operation. To prevent this inconvenience, we have thought 
of fitting a movable ring to the extremity of the sound 
which receives the end of the cord, by which we may 
tighten the extremity of the sound at pleasure, and thus fix 
firmly the portion of the cord within it. (See PL LXIII.) 

We ought not to omit mentioning a very serious circum- 
stance which may occur at the moment the uterus is 
divided. Suppose, in fact, that the placenta is attached to 
the inner face of the uterus, in that part corresponding to 
the incision of this organ, we must necessarily make a 
large wound in it ; this might occasion hemorrhage, which 

19 



154 MIDWIFERY ILLUSTRATED. 

would be more dangerous, because most of the fluid would 
come into the cavity of the uterus, and some also might be 
effused into the abdomen. 

However serious this accident might be, we must deliver 
the placenta, and even remove its divided portions through 
the wound in the uterus, as quickly as possible'. This is 
the only mode of arresting the hemorrhage, and of prevent- 
ing the danger which might attend the mother from the 
more or less prolonged continuance of the portions of the 
placenta in the uterus. 

When the delivery of the placenta is happily termi- 
nated, the female must immediately be put to bed, in a 
slightly bent position, and the most perfect rest must be 
enjoined. 

Some practitioners have proposed to apply sutures to the 
edges of the wound of the integuments, to keep them in 
contact, and to favor the formation of a cicatrix : but we 
prefer simply strips of adhesive plaster. Some compresses 
placed gently on the wound, and a loose body bandage 
complete the dressing. In fact, if the operation be success- 
ful, the uterus in contracting soon effaces the incision made 
to remove the child : the cicatrization of the external 
wound not being prevented, the female may be perfectly 
well in a few days. 

Such is the ancient mode of performing the Cesarean 
operation : it is generally employed, even by the moderns, 
but its severe inconveniences have induced practitioners to 
substitute others for it. In fact, it is evident that in this 
mode of performing the operation, the abdominal muscles 
are divided in different directions, and the transversalis 
abdominis muscle is not cut across, which might retard the 
cicatrization of v the external wound. Farther, in perform- 



MIDWIFERY ILLUSTRATED. 155 

ing the operation in this manner, we cannot always avoid 
the epigastric artery, and some of its large branches, and 
even the uterine artery and the appendages of the uterus. 
The placenta too, which is often inserted in the sides of 
this organ, may also be interested in a greater or less extent, 
and thus give rise to the most alarming hemorrhages. 
Finally, the place in which the operation is performed, may 
not always be large enough, on account of the deformity of 
the person operated upon, which is sometimes very great. 
Such are the inconveniences, we might almost say the acci- 
dents, which attend the Cesarean operation performed after 
the manner of the ancients, which have led practitioners to 
make the incision of the abdomen along the linea alba. 
This mode of operating is termed Beaudeloque's mode. 

Beaudcloqutfs Mode. The division of the abdominal 
muscles in the Cesarean operation, has always been con- 
sidered by practitioners as a serious circumstance. Violent 
inflammations, the length of time necessary to the cicatri- 
zation, and the dread every moment of seeing portions of 
the intestine escape externally, are in fact very common 
consequences. 

The last considerations led Beaudeloque to propose to 
make the incision in the abdomen along the linea alba. In 
this mode of operating, the fleshy part of the abdominal 
muscles is not concerned ; we also avoid all the other 
inconveniences mentioned above, but it also presents 
. remarkable disadvantages which we shall mention after 
describing the operation. 

In this process, the parietes of the abdomen are divided 
along the linea alba, and the incision is equal in extent to 
that made on the side in the former mode. This incision 
commences at two or three fingers' breadth above the urn- 



156 MIDWIFERY ILLUSTRATED. 

bilicus, which must be avoided, passing on the side of it, 
and terminates three fingers' breadths above the pubis. In 
this manner nearly all the linea alba is divided, and exposes 
the uterus, in which an incision is made, perfectly like that 
mentioned in the former mode. The other steps of the 
operation are exactly like those mentioned above : we shall 
not repeat them here. 

This process, as we have described it, is doubtless more 
simple than the preceding, since all the inconveniences 
mentioned in the operation, as performed by the ancients, 
are avoided ; but it presents some others which we must 
mention, such as the length of the cicatrix, and the extreme 
difficulty of its healing : this exposes females to hernias, 
which are more difficult to reduce and to prevent, because 
the parietes of the abdomen present no resistance to their 
formation ; on the other hand, if females who have been 
operated upon become pregnant again, they are exposed to 
new hernias which may be extremely large, and also to all 
the bad symptoms which they cause. 

We have now to say one word of Lauvergeat's mode, 
which, like the preceding, presents some advantages and 
disadvantages : but this differs very much in respect to the 
place and direction of the external incision. 

JLauvergeafs Operation. This scientific practitioner, 
struck with the great inconveniences attending the longi- 
tudinal division of the fibres of the transversalis muscle, 
and with the difficulty resulting from it in the cicatrization 
of the external wound after the Cesarean operation as 
performed by the ancients, proposed to make a transverse 
instead of a longitudinal incision of the abdominal muscles. 
In this mode of operating, in fact, the fibres of the trans- 
versalis muscle are scarcely touched; they are separated, 



MIDWIFERY ILLUSTRATED. 157 

rather than divided : and if the operation be successful, the 
cicatrization of the external wound, favored by the flexed 
position of the patient, is very easy. 

But this mode, on the other hand, presents so great disad- 
vantages, that it has been nearly abandoned by practition- 
ers, who generally prefer one of the two preceding processes. 
It is, in fact, remarkable for this, that when the operation 
performed in this manner is to be successful, it must perhaps 
be rejected : for then the incision of the uterus being sud- 
denly brought below that of the integuments, by the quick 
contraction of this organ, one part of the lochise must 
inevitably escape into the belly, and cause there serious 
accidents. (See PL LXIV.) 

It follows, from these remarks, that of the three modes of 
performing hysterotomy, the operation of the ancients is 
most inconvenient, although perhaps it is more easily prac- 
tised ; and it is also advantageous as allowing an easy issue 
to the lochias, which sometimes escape through the wound 
in the uterus : so that Beaudeloque's mode seems preferable 
to the other two, although the only one which is attended 
with such fatal consequences : we allude to the difficulty of 
cicatrization, and the inevitable formation of hernias. As 
to Lauvergeat's mode, its advantages do not compensate 
for the inconveniences which often attend it, and we think 
it should never be performed. 

M. Beaudeloque, jun. has recently proposed a new pro- 
cess which deserves the attention of practitioners. Our 
limits prevent us from stating it.* 

* The following account of M. Beaudeloque's jun. mode of performing the 
Cesarean operation, is from Dr. Meigs 1 translation of Velpeau's Midwifery. 

" The incision is commenced near the spine of the pubis, and extends, paral- 
lel to Poupart's ligament, beyond the antero-superior spine of the ilium. He 



158 MIDWIFERY ILLUSTRATED. 



OPERATIONS PERFORMED ON THE DEAD CHILD. 

Before treating of the different operations performed upon 
the dead child, we shall mention the signs by which its 
death may be proved. It may have been dead for several 
days, or it may have died during labor. In the first case, 
the child is generally in a more or less advanced state of 
decomposition, according to the nature of the causes which 
have destroyed it. In the second case, on the contrary, it 
is always uninjured, and of the strength and size of a full 
grown child. The causes of its death, in the first case, are 
very various, and their peculiar nature cannot always be 
determined. This is not true in the second case, in which 
the length of the labor, the power and energy of the uterine 
contractions, may be considered as the only and real causes 
of the child's death. 

The following phenomena are usually observed in the 
first case : the female, who has hitherto felt distinctly the 
motions of her child, perceives that they grow more and 

selects the left side, on account of the inclination of the cervix, when the 
womb is oblique to the right, and the right side where there is a left lateral 
obliquity. After having divided the abdominal parietes without touching 
the epigastric artery, he pushes away the peritoneum from the iliac fossa, 
quite down into the excavation, and detaches it from the upper part of the 
vagina, which he opens ; through this opening, which ought to be sufficiently 
free, the finger is conducted into the os uteri, which is now to be drawn up 
towards the wound in the abdomen, while the fundus is at the same time 
pressed in an opposite direction, so as to make it turn over more readily. 
When the operator has succeeded in bringing the orifice of the womb opposite to 
the opening made in the abdominal parietes, the delivery is intrusted to the 
uterine contractions, or provided it should be absolutely necessary, the orifice 
might be dilated with the fingers, and the fetus extracted either with the hand 
or the forceps." 



MIDWIFERY ILLUSTRATED. 159 

more feeble, and they finally cease. The belly then be- 
comes flaccid, and as it were undulating : the female per- 
ceives an inconvenient weight, and a kind of ball which 
rolls about in her belly, and which is always felt on the 
side toward which she inclines. The mammse collapse, and 
are flaccid : the head becomes embarrassed: the eyes are 
moist and suffused, and often surrounded with a bluish 
circle : the nose becomes sharper, the lips lose their color, 
and there is a general paleness of the whole face : the 
mouth becomes thick, and has a bitter taste : the appetite 
is lost, and the digestion is deranged : the urine is muddy 
and thick: a colliquative sweat frequently appears: the 
female seems sad and watchful, and the sleep is often inter- 
rupted by harrassing dreams : sometimes a more or less 
marked jaundice is seen on some separate parts of her body. 

Finally, in such cases, the membranes are frequently 
ruptured without the knowledge of the female, and the 
cord is wasted, soft, pulseless, and then escapes, either into 
the vagina or through the external organs of generation, 
accompanied with the discharge of a greater or less quan- 
tity of water, which is sometimes clear, sometimes turbid, 
yellowish, &c. If we now examine the female by touch- 
ing, we feel the soft flexible head, and the bones of the 
skull lap over each other easily. 

It is more difficult to determine when the child dies during 
labor, because then the death is not sudden, but on the 
contrary very gradual, since the female still thinks its mo- 
tions are perceptible long after life is extinct. The accou- 
cheur, however, may be satisfied of the child's death when, 
during a severe labor, the pains instead of becoming stronger 
and more intense, are on the contrary more feeble, when 
the female loses her strength and courage ; when the belly 



160 MIDWIFERY ILLUSTRATED. 

evidently collapses; when the hairy scalp of the fetus, 
which was hard, tumefied, and resisting, becomes soft and 
flaccid, and glides over the surfaces of the bones as if 
detached from them. 

Such are the different signs by which we can determine 
the death of the child, either during labor, or long before 
its commencement. Let us now mention the different ope- 
rations to remove the child, in both cases. 

I. When the head presents, and all the common modes 
employed to bring it into the cavity of the pelvis have failed, 
either on account of its volume, or from the narrowness of 
the pelvis, we must decide upon opening the skull, and re- 
moving most of the cerebral mass. This operation is 
termed encephalotomy. The manner of performing it is as 
follows : the female being placed in a proper position, a 
perforator is introduced, by which a part of the hairy scalp 
is divided in the direction of a suture, or at one of the fon- 
tanelles. This first incision finished, the instrument is 
withdrawn, and Smellie's scissors are substituted, which 
are introduced deeply into the skull. They are then sepa- 
rated, and extended in every direction, enlarging the open- 
ing through which most of the cerebral mass is removed. 
(See PL LXV. Fig. 1 and 2.) 

Although the head, thus diminished by the removal of 
the brain, may easily pass through the pelvis, the child is 
rarely left to the natural efforts of the uterus : on account 
of the bad symptoms which might follow, the labor must 
not be intrusted to the efforts of nature; and it is more 
prudent to terminate it by art. 

In this case, however, we must not use the common for- 
ceps to extract the child; for the head being necessarily 
smaller and less resisting, the instrument may slip, and 



MIDWIFERY ILLUSTRATED. 161 

injure or even tear more or less deeply the parts of the 
mother. 

Among the means indicated in this case, we may use first 
any extractor by which we may perhaps bring down the 
head. (See PL LXVL Fig. 1.) But in this operation, the 
bones of the child's skull, already partially broken, may 
possibly yield too easily to the action of the instrument, and 
frustrate the operation : hence some practitioners prefer to 
apply a sharp crotchet, which is introduced at first very 
deeply within the uterus, and then on withdrawing it, we 
attempt to fix it on the child's head, and thus remove the 
child. 

But however advantageous this process may be, we can- 
not conceal its dangers : in fact, in the very violent efforts 
sometimes necessary to remove the child, the crotchet is 
liable to tear into folds the part of the head to which it is 
applied, and by coming forth quickly and unexpectedly, to 
lacerate the parts of the mother deeply. 

The crotchet-forceps, improved by us upon that of 
Smellie, seems preferable in every respect. It is applied 
like the common forceps ; and with this instrument we may 
pull violently upon the child's head without fear of its 
slipping; and suppose even that it should give way, the 
parts of the mother are never exposed, for the crotchets are 
placed within the blades, and can in no manner tear or 
bruise her. (See PL LXVL. Fig. 2.) 

II. When the child has died from some of the causes of 
debility already mentioned, and it has begun to decompose, 
there is commonly a more or less abundant discharge, 
either in the head or in the abdominal cavity ; they then 
become very large, when all the other parts of the child are 
on the contrary very small, and as it were wasted. 

20 



162 MIDWIFERY ILLUSTRATED. 

Those parts likewise, which are brought towards the 
opening of the pelvis by their weight, are also those which 
are generally found near the upper strait, through which 
they are too large to pass. The indication in both cases is 
simple : we may even premise that labors of this kind are 
extremely easy, as soon as the obstacle which opposed their 
termination is removed ; which is done by evacuating the 
effused fluid through an opening made with any sharp 
instrument, 

Thus when the belly presents, and after satisfying our- 
selves of its existence, we introduce with proper precau- 
tions a trocar. (See PL LXVII. Fig. 1.) The effused 
fluid immediately escapes, and the parts collapse instantly : 
we may then bring down the feet, and terminate the labor 
without difficulty. 

But if the child be affected with hydrocephalus, and the 
head is much larger than the opening of the pelvis, through 
which however it must escape, we must remove the effused 
fluid, either by perforating the parts with the trocar, or 
with one of the extractors mentioned above. The opera- 
tion in this case presents no difficulty : we have only to 
carry the point of the instrument through the enlarged 
opening of any suture, and thus to penetrate deeply into 
the skull of the child, and a great quantity of fluid w T ill be 
discharged. The skull collapses, and the labor soon 
terminates. 

The same course must be pursued if the feet are brought 
down, and the head, arrested at the superior strait, should 
be prevented from coming farther. Perhaps it is not so 
easy, in this case, to place the end of the instrument 
just in the interval of a suture ; but the bones of the skull 



MIDWIFERY ILLUSTRATED. 163 

resist but slightly, and we easily penetrate within it, and 
evacuate the fluid. (See PL LXVIL Fig. 2.) 

III. Sometimes an imprudent person, by pulling violently 
on the child's feet to deliver it, may separate the trunk 
from the head, which is left within the uterus. This is a 
serious case, as the attendants are terrified, and it is difficult 
to seize and extract the head. 

If the head, when thus separated, remains movable with- 
in the uterus, it will not always be prudent to deliver it im- 
mediately by art. The action of the uterus alone, by placing 
it favorably across the strait, sometimes expels it ; but this 
is very rare, and as the head has been separated from the 
trunk by violent efforts, it follows that it is most generally 
fixed and even partly engaged through the superior strait, 
the occipital foramen looking towards the external organs of 
generation. This last circumstance is fortunate, inasmuch 
as we can easily introduce any extractor into the child's 
skull, and we can thus bring it into the cavity and conse- 
quently out of the vulva : but all the extractors, and even 
that figured by us (See PL LXVIII, Fig. 1.), are very in- 
convenient in their application, as they engage and remove 
the bones of the child's skull, by the force sometimes re- 
quired to extract the head ; and when this occurs it cannot 
be remedied, and this mode must be renounced. We do 
not therefore recommend the use of the extractor unless 
we are almost certain of removing the head, without being- 
obliged to make too great efforts, or when we are in want 
of the necessary instruments to supply it. 

In a similar case, and for the same reasons, it has been 
recommended to use a small stick, an inch and a half long, 
to the centre of which is attached a cord, long enough and 
strong enough to fulfill the object proposed. The stick is 



164 MIDWIFERY ILLUSTRATED. 

introduced lengthwise into the skull, through the occipital 
foramen : it places itself crosswise : we then draw upon it 
to remove the head : but this mode, like the preceding, can 
be accomplished only when the occipital foramen has the 
proper direction : in the contrary case, being perfectly use- 
less, we must employ the crotchet. At first a single crotchet 
is used, which is introduced without any other precaution 
than that of applying it in some part of the child's head. 
But we have already mentioned the great inconveniences of 
applying a simple crotchet, and to avoid them, we advise 
the use of our forceps with a double crotchet, which secures 
the mother from all accident, and presents advantages 
offered by no other. The head being seized properly, is 
delivered without difficulty, whatever may be the resist- 
ance. (See PL LXVIII. Fig. 2.) 



OF DELIVERY. 

The term delivery is applied to that part of the labor in 
which the placenta, the membranes, and the umbilical cord 
are expelled or extracted. The delivery is divided into 
natural and artificial. 

Natural delivery. In natural delivery we have to con- 
sider it as occurring at the end of pregnancy, before this 
time, and in the case of compound pregnancy. 

A. Natural delivery at the full 'period. In every natural 
delivery occurring at the end of pregnancy, whether simple 
or compound, there are tw T o very distinct periods. The 
first is that during which the uterus by its successive and 
constantly increasing contractions, is finally more or less de- 
tached from the placenta, which is then loose, and as it 



MIDWIFERY ILLUSTRATED. 165 

were floating within this organ at the moment when the 
child is born. The second period is, according to most 
writers, the proper delivery ; during which the accoucheur 
removes the placenta and the membranes from the genital 
organs, using that part of the umbilical cord delivered with 
the child. 

The first period of natural delivery occurs without our 
aid ; the second requires it. The following is the manner 
of proceeding. 

Soon after the child is born, the female is perfectly quiet, 
except that she is a little disturbed by the fear of new pains 
which may be occasioned by the delivery : this latter is in 
fact generally attended by rather severe colics, which indi- 
cate that the uterus in contracting, attempts to expel the 
placenta and its membranes. 

In order to excite these pains, when they are not sponta- 
neous, the abdomen must be rubbed. This simple and easy 
thing is generally sufficient to renew the action of the 
uterus, which can be felt in this case as high as the umbili- 
cal region : at this time also, we must draw the cord gently, 
in order to deliver the placenta. 

To accomplish this, the index finger of the left hand 
takes several turns of the cord, while the index finger of 
the right hand glides along the cord to the mouth of the 
uterus, in order to determine the presence of the placenta : 
we then move the cord in different directions ; the placenta 
is easily brought into the vagina and removed : but before 
extracting it entirely, it is well to turn it round several times, 
in order to twist the membranes, which in this case are not 
so liable to be torn, and consequently to be left in the 
uterus in greater or less portions, which might occasion 
several bad symptoms, (See PL LXIX. Fig, 1 and 2.) 



166 MIDWIFERY ILLUSTRATED. 

Sometimes the secundines are so large that they cannot 
be delivered, and stop at the orifice : then, while we rub 
the abdomen in the hypogastric region with one hand, and 
pull gently on the cord, two other fingers of the opposite 
hand are introduced to the placenta, which is removed by 
inserting if necessary one finger into its substance, and 
using it as a hook. 

The same mode of proceeding should be adopted, if the 
umbilical cord should by any means be ruptured near the 
body of the placenta. (See PL LXX. Fig. 1.) 

B. Of the premature delivery. Premature delivery must 
be considered in three different points of view : first, during 
the first three months of pregnancy ; second, during the 
three following months; third, during a part of the last 
three months. 

During the first three months, the delivery must be regu- 
lated by general rules. The following is what occurs most 
generally in abortions at this period, relative to the delivery 
of the placenta. The same pain frequently expels the 
fetus, and the small placenta which attends it ; sometimes, 
however, the fetus is expelled separately, and the placenta 
comes immediately after ; but the latter frequently remains 
several days, a month, and even more. The most prudent 
mode in these different cases is, to leave all to nature, 
which sooner or later expels this foreign body. 

In the middle three months of pregnancy, the delivery 
differs a little from what we have mentioned : but as in the 
course of the fifth, and particularly the sixth month, the 
fetus has acquired a certain size, and the placenta is much 
developed, the neck is obliged to open considerably to allow 
the child to pass : hence it follows, that if in this case the 
placenta is not delivered immediately after the fetus, we 



MIDWrFERY ILLUSTRATED. 167 

ought to be as careful as possible, and preserve the small 
umbilical cord, which is still attached to the placenta, and 
must be used to extract this latter, when it is completely 
detached from the inner face of the uterus. In the opposite 
case, if the neck remained open, we might seize the whole 
or a part of the placenta, with the abortion forceps : but 
this must be done with the greatest prudence. {See PL 
LXXI.Fig.2.) 

The delivery in the last three months of pregnancy differs 
so little from what we have mentioned above, when speak- 
ing of delivery at the full period, that we think it super- 
fluous to enter into new details on this subject. 

C. Of delivery ', in case of compound pregnancy ', and at the 

full period. The general rules laid down in the case of 

simple pregnancy and at the full period, apply in great 

part to the delivery in compound pregnancy : they differ, 

however, in some respects, which we shall mention. 

Although in compound pregnancy children are born suc- 
cessively, it does not follow that each placenta should be 
delivered after each child : delivery in this case should be 
at one time, and all the placentas should be removed at 
once, being careful to pull rather upon the placenta of the 
child first delivered, and successively on the second, third, 
&c. ; admitting that the pregnancy was with twins, 
triplets, &c. 

Artificial delivery. The circumstances which require an 
artificial delivery are very numerous. They may however 
be reduced to the following : first, inactivity of the uterus, 
attended or preceded by hemorrhage, convulsions, or re- 
peated faintings ; second, insertion of the placenta over or 
on the edges of the os tincee ; third, an encysted state of a 



168 MIDWIFERY ILLUSTRATED. 

part or of the whole of the placenta ; fourth, its unnatural 
adhesion. 

A. Unnatural adhesion of the placenta. Even after the 
most natural labor, it is often extremely difficult to extract 
the placenta. Constant frictions of the abdomen, and all the 
usual means fail to detach the placenta from the inner face 
of the uterus, with which it continues intimately connected; 
the uterus, however, has contracted : the female expe- 
riences no bad symptoms ; she is calm and tranquil ; but 
she is not delivered, and the time passes in useless expecta- 
tion. In this extraordinary case, practitioners advise us to 
wait : we, however, are not of this opinion : we think that 
prudence requires an entirely opposite course. When once 
the child has left the uterus, the placenta is only a foreign 
body, and its too long continuance in the cavity of the 
uterus, often causes severe symptoms. For these reasons, 
the placenta should be removed when it is not detached 
from the uterus, and the female is not delivered after 
an hour or two at most. The following is the mode of 
proceeding. 

The female lying down, the umbilical cord is grasped 
with two or three fingers of the left hand, and the right 
hand is immediately introduced within the uterus ; guided 
thus by the umbilical cord, it is directed to the place where 
the placenta is attached. If this spongy mass adheres to 
all points of the surface of the uterus, we begin to loosen it 
on the side corresponding to the hand which is introduced : 
continuing in this manner, we can easily detach it com- 
pletely, and immediately bring it entire towards the neck, 
being careful to remove at the same time the membranes, 
and the clots which may have been formed in the uterus. 



MIDWIFERY ILLUSTRATED. 169 

Where the placenta is partially detached, when the hand 
is introduced into the uterus to deliver the female, we must, 
as it were, continue the separation of the placenta by this 
floating portion. In this manner the operation will be less 
difficult for the accoucheur and less fatiguing to the female. 
(See PL LXXL Fig. 1.) 

B. Of delivery, when the uterus is inactive. The inactivity 
of the uterus, which supervenes before the female is de- 
livered, is most commonly attended w T ith hemorrhage or 
repeated faintings. These latter symptoms more particu- 
larly require an artificial delivery : as the presence of the 
placenta in the cavity of the uterus must be considered the 
material cause of this inactivity, which if not dependent on 
this cause, is protracted by it. In both cases there is but 
one reasonable course to pursue, which is to remove the 
placenta, observing the precautions already mentioned. 
One advantage, at least, results from this course, viz., that 
if the inactivity of the uterus continues after the placenta 
is delivered, we may then employ the means necessary to 
remove it, which would not always be possible before the 
delivery. 

C. Of delivery, where the placenta is attached over or on the 
edges of the os tincce. The attachment of the placenta over 
the orifice of the uterus or on its edges, is one of the most 
remarkable and also the most fatal case in practical ob- 
stetrics. Here the delivery takes place sometimes before 
the birth of the child. Farther, in the case before us, the 
delivery is not exactly the most important point, but rather 
the appearance of the child, whose life is generally in great 
danger. 

When the placenta is attached over the orifice of the 
uterus, and on account of the continuance of the labor, its 

31 



170 MIDWIFERY ILLUSTRATED. 

termination cannot be deferred, we cannot reach the child 
except by passing through the placenta, or rather, as some 
practitioners have advised, by detaching it circularly by 
means of several fingers passed between it and the parts 
near the neck of the uterus : but this course has always 
appeared to us hazardous and often even impracticable, 
and therefore we fearlessly pass through the placenta, 
which is necessarily preforated, in order to arrive at the 
child. What is there to fear in employing this method? 
The detachment of the placenta ? this is desired : the lace- 
ration of the placenta ? but the child must be saved, and 
the mother suffers from the effects of a long continued 
hemorrhage. When the labor has terminated, we immedi- 
ately collect the detached parts of the placenta and remove 
them entirely from the uterus. We must attend to one 
thing strictly : we must employ promptly the most ener- 
getic means for restoring tone to the uterus, for the female 
dies if its inactivity continues. (See PL LXX. Fig. 1.) 

The case is not so serious, nor the danger as pressing, 
when the placenta is inserted only on a part of the edges of 
the os tincae. The duty of the accoucheur is also very dif- 
ferent, as respects the manner of delivery ; which must not 
be effected, in this case, until after the child is born. 

If we proceed methodically, and regard the interests of 
the mother and child, we must separate, during each pain, 
the placenta from the neck of the uterus, and this ma- 
noeuvre must be continued until the membranes pass 
through its opening, and the bag of waters is well formed. 
This latter must then be ruptured after a severe pain, in 
order that the head of the child, placed behind, may engage 
itself in its turn through the neck, and thus form a kind of 



MIDWIFERY ILLUSTRATED. 171 

natural plug, which will be for the time the surest means 
of arresting all hemorrhage. (See PL LXX Fig. 2.) 

D. Of delivery, where the placenta is encysted. The pla- 
centa can be encysted only in consequence of a partial 
contraction of the uterus, while the portion to which the 
placenta is attached remains inactive. The uterus is then 
as it were divided into two unequal cavities, one of which, 
that nearer the neck, is powerfully contracted, and the 
other, which is more remote, is in a state of relaxation. 
This circumstance is rather frequent in practice, but the 
consequences of it are rarely dangerous. The indications 
presented by the delivery in this case, are nearly the same 
as those of the delivery of the placenta, where there is an 
unnatural adhesion. Thus, after having uselessly attempted 
to excite the action of the uterus near the place where the 
cyst is formed, the hand must be introduced into the uterus, 
carrying it by the aid of the cord, to the place where the 
placenta is situated. If, as is more frequently the case, a 
greater or less portion of the placenta is engaged, and as it 
were strangled through the kind of neck formed by the 
contracted portion of the uterus, this loose portion of the 
placenta must be used to deliver the rest, by pulling gently 
upon it. If, on the contrary, the whole placenta is so in- 
closed in the cavity of the uterus, that we cannot take hold 
of any portion of it in order to delivery, we must by a forced 
dilatation, penetrate into the pouch which contains the pla- 
centa, separate, and deliver it. (See PL LXXI. Fig. 2.) 

E. Of some other circumstances of artificial delivery. The 
operations practised on the child do not require any pecu- 
liar directions in regard to the delivery, which most gene- 
rally occurs in this case as in the most natural labor : the 
same is true of the operation of symphysiotomy, after which, 



172 MIDWIFERY ILLUSTRATED. 

the delivery, as in the preceding case, may take place in 
the most simple and natural manner. Only the Cesarean 
operation then, in this respect, presents some particular 
indications, which we have already mentioned. 



INSTRUMENTS USED IN OBSTETRICS. 

How the times are changed ! The practice of obstetrics, 
which was formerly so complicated in its means, so frightful, 
particularly from the number of the instruments used by 
accoucheurs, has undergone, in our days, a very salutary 
change. Thanks to the lights thrown upon this latter 
branch of science, by the advance of surgery in general, 
and particularly of obstetrics, the number of instruments 
is singularly diminished, and is now confined to those which 
are the most indispensable. 

As we do not intend to describe these instruments in 
detail, we shall merely define them, stating more par- 
ticularly our opinion of their real mechanism, and their 
advantages. 



PLATE LXXIII. 

Forceps. Of all the instruments which have been intro- 
duced into the science of obstetrics, the forceps has been 
most remarkably and most happily successful : its invention 
forms a memorable epoch in the records of the art, and the 
services it has since rendered prove its excellence, and the 
necessity of its employment. 

The forceps is too complicated for us to give a detailed 



MIDWIFERY ILLUSTRATED. 173 

description ; it is composed of two blades which are crossed 
and attached by a movable pivot and mortise. 

A well made and well proportioned forceps should be 
from seventeen to eighteen inches long ; the joint should not 
be exactly in the centre of the instrument, but about an 
inch nearer the extremity of the handles. This extremity 
should be curved in the form of a blunt crotchet. 

If the handles are of wood, {Dubois forceps) the thick- 
ness of the steel portion to which they are attached, is of 
little importance : if the contrary be true, the handles 
should be sufficiently strong and thick, to give support 
during their application. The blades are well arched, and 
well rounded, and must present an oval, the large extremity 
of which should be towards the point of the instrument, 
and the small towards the joint. Its greatest breadth is 
situated between the anterior and the two posterior thirds, 
and should be two and a half inches. These dimensions 
must be particularly regarded. 

The forceps should be made of steel, and not of iron : 
when formed of the latter material, it is heavy, and gets out 
of shape : when of steel, on the contrary, it is lighter, gives, 
and does not get out of shape. In that generally used by 
us, the key has a new form. This hinge acts circularly, and 
not from above downward, as in other forceps. 

Lever. This instrument was invented by Roonhuisen, 
who has overrated its advantages : it is now, however, 
valued as it should be, and is employed only in some rare 
cases, where the head being placed in an unfavorable posi- 
tion in respect to the superior strait, requires only a slight 
movement to cause it to pass down. 

It is particularly necessary to employ it, when the hand 



174 MIDWIFERY ILLUSTRATED. 

alone cannot cause the head to perform the motions required 
by its bad position. 

The lever is, in fact, only one blade of the forceps, the 
curve of which is much less marked, and has none on the 
side like this latter. It always has a wooden handle. Our 
remarks on the construction of the forceps are applicable 
to the lever also. 

Forceps of Dr. Guillon. This instrument differs from the 
preceding, not in its mode of action, but in the form of the 
joint. It has neither pivot nor mortise ; and the mechanism 
of its union, which is very simple, removes all difficulties 
which so often attend the union of the blades of the com- 
mon forceps. The handles also contain several compart- 
ments, in which are different objects, useful either in apply- 
ing the forceps, or in some other operations of practical 
obstetrics. 

Crotchet forceps. The first idea of this instrument belongs 
to Smellie, but we have made several important alterations 
in it. Its form is exactly like that of the common forceps ; 
but it differs in respect to the mode of uniting the blades, 
as also by the two crotchets which are curved inward, and 
in which' the blades terminate, and which are designed par- 
ticularly to be applied to the head of a dead child, in every 
case where its delivery is prevented. 



PLATE LXXIV. 

Callipers and pelvimeter. The callipers, and also the pel- 
vimeter of Coutuly, are much overvalued, and are rarely 
employed in common practice. Should we not express an 
opinion in regard to the result of their application we 



MIDWIFERY ILLUSTRATED. 175 

must admit that their mechanism is very ingenious, and 
that they fulfill perfectly the conditions proposed by their 
inventors. 

The callipers especially have a great advantage over the 
pelvimeter, as they may be applied to the external parts of 
the female, while this latter, introduced into the vagina, 
must pass entirely through it. 

This is the great defect of all instruments of this kind. 
We shall not except the pelvigraphe of M. Martin, which, 
although complicated in its mechanism, and even difficult in 
its application, is still a very ingenious, and an entirely 
new invention. 

It is, in fact, arranged so that while one moveable arm, 
introduced into the vagina, describes the circumference of 
the pelvis, another arm, placed in the form of a point on a 
small plate arranged for this purpose, traces perfectly the 
exact figure of the pelvis, passed over by the arm which is 
introduced. 

The common compasses and the rule, are placed on the 
same plate, merely to show them. 



- PLATE LXXV. 

Symphysis knife. This is not a new instrument, but 
simply a common bistoury, to which we have thought pro- 
per to give a particular form, and more proper for the kind 
of operation to which it is designed. The blade is short, 
probe pointed, with a broad back, and a long strong and 
square handle. We must observe that the fibro -cartilage 
of the symphysis pubis is very firm, and it is difficult to cut 
with a bistoury which has a thin and narrow blade. If the 



HG MIDWIFERY ILLUSTRATED, 

operator supports it feebly, the fibro-cartilage is not cut ; he 
bears upon it more firmly, the blade of the bistoury breaks, 
and may wound the female. With the symphysis knife, as 
made by us, this double inconvenience need not be feared. 

The two bistouries, and the two pairs of scissors, placed 
on the same line as the symphysis knife, present nothing 
particular, and are there merely to show them. 

Perforator. Under this term is designated any sharp 
instrument, by which we penetrate into the skull of the 
dead fetus, to remove the mass of the cerebrum. There 
are several kinds of them, as the common perforator, that 
of Bacque, and the scissors of Smellie. 

The common perforator, (perce crdne) is composed of a 
long iron arm, terminated by a spear point, and has a solid, 
round handle, four or five inches long. The whole instru- 
ment ought not to be less than from sixteen to eighteen 
inches in length. 

The perforator of Bacque, which is also termed an ex- 
tractor (tire tete) is much more complex than the preceding, 
and is used both for a perforator and an extractor : it is 
composed of a blade attached to a handle, on which glides 
at pleasure a second moveable arm : this is terminated by 
a sharp extremity, on which rest two pieces which are 
perfectly adapted to this blade when it acts as a perforator, 
and which are extended on the sides when the instrument 
is used as an extractor. 

Nevertheless, whatever may be the advantages of this 
instrument, we prefer in the latter case our crotchet forceps. 

Smellie's scissors act very differently from the preceding : 
they may, it is true, serve for a perforator : but when once 
introduced, we can enlarge at pleasure the opening made by 



MIDWIFERY ILLUSTRATED. 177 

them, by moving their extremities, the cutting edge of which 
is outward. 

The new extractor which we have drawn, is limited in 
its employment, and is destined to be introduced through 
the occipital foramen within the head of the fetus, when 
this latter has been detruncated, and this opening has a 
proper direction to allow of its introduction. The arm at 
the top may be fitted at pleasure to the common blade, 
wiien we wish to introduce it, and afterwards placed across, 
by the aid of a movement of the base ; all which is easily 
performed by a piece of silk, arranged for this purpose. 

This instrument is very simple in its mechanism, and is 
designed to replace the small rod advised by Beaudeloque : 
a mode, however, which should not be neglected in the 
cases where it is necessary to use it. 



PLATE LXXVI. 

Sound for delivery. This is to be used only in the Cesa- 
rean operation, when we decide to bring the extremity of 
the divided cord through the wound of the uterus within 
this organ, in order to deliver it by the natural passages, 

The sound should be from fifteen to eighteen inches long, 
with one blunt extremity; the opposite extremity open, 
broad, and cleft at its circumference : a movable ring is 
designed to close the sound, and to fix firmly the end of the 
cord inserted in it. The sound must necessarily be intro- 
duced by the blunt extremity, carried towards the neck in 
order to glide it into the vagina, where it must be grasped 
in order to deliver it, and with it the portion of the cord 
attached to it, 

22 



178 MIDWIFERY ILLUSTRATED. 

Repoxissoir. This instrument, the uses of which we were 
the first to indicate, is not for this reason a new instrument : 
it is rather a new idea, perhaps, applied to an instrument 
already known, and employed for a new purpose. It is, in 
fact, designed particularly to act on the head, to push it 
backward, while on the other hand the practitioner pulls 
on the feet to bring them outward. 

This instrument is composed of a handle from eight to 
ten inches long, surmounted at one end by a cross-piece 
which is covered with chamois leather, which protects the 
head from the painful pressure of the naked wood or ivory. 

Porte cordon. Of the two instruments figured with this 
name, one belongs to Ducamp ; the other was invented by 
Dr. Guillon, who kindly gave us the drawing of it. 

It seems that Ducamp took the first idea of his porte 
cordon from the English. Although its mechanism is 
rather complicated, the idea is extremely happy, and the 
instrument is perfectly fitted for the end proposed in its 
application. 

The porte cordon of Dr. Guillon, is very like the pre- 
ceding, but differs from it in the form of the ring, which 
opens in two parts only, and which being more simple in its 
mechanism, is preferable to that of Ducamp. 

Abortion forceps of Levret. This forceps does not differ 
from other instruments of this character, except in the form 
of the blades, which are grooved, and not plain. Its length 
should be from twelve to fifteen inches, in order to introduce 
it sometimes very deeply. 

The small foot of a child seen on this plate, gives an 
idea of the mode in which fillets should be applied. 



MIDWIFERY ILLUSTRATED, 179 



OF LACTATION. 

No sooner is the product of conception delivered, than 
the functions of the genital organs immediately cease ; but 
the lively irritation which attended them during pregnancy 
is not entirely removed : another system of organs inti- 
mately connected with those of generation, then becomes 
the seat, and as it were the rendezvous of all nature's 
efforts, who is particularly attentive to the preservation of 
the child. 

In order to this, a sweet, saccharine, and very nutritious 
fluid is deposited in the mammae, which easily escapes from 
the canals which contain it, and which is discharged 
abundantly by the least suction of the child, or the least 
titillation. These phenomena constitute lactation. 

Description of the mammce. The mammae are developed 
but slightly in young females, but increase rapidly about 
the age of puberty ; they then rise, become semi-spherical, 
separate from each other, and assume a firmness and con- 
sistence, which disappears in those females who have borne 
children, and who have nursed. 

The skin which covers them is white, tender, and soft ; 
from the centre rises a prolonged prominence, called the 
nipple, which is surrounded by an areola : both of these 
are of a delicate red in girls, and a brownish color in 
females. {See PL LXXVIIL Fig. 2.) 

The mammae are composed of the mammary gland, the 
milk passages, the nipple, and the areola. 

The mammary gland occupies the centre of the mamma ; 
it is surrounded and, as it were, imbedded in a mass of 



180 MIDWIFERY ILLUSTRATED. 

fatty cellular tissue, one portion of which enters and even 
engages itself in its proper tissue. 

The gland is of a grayish red color, its consistence is 
firm, and its form is globular. The vessels which pass 
through it are very minute, and are extremely difficult to 
inject. (See PL LXXIX. Fig. 1 and 2.) 

The nipple appears as an elongated rounded body, covered 
with a corrugated and cracked skin, of a more or less deep 
red color in those females who have borne children, and 
surrounded at its base by a circle of the same color, termed 
the areola : this latter is covered by an epidermoid surface 
of the same nature as that which envelops the nipple. 

Maceration easily detaches this particular kind of epi- 
dermis, which in fact is only a superfluous portion of the 
real epidermis of these parts. (See PL LXXVIII. Fig. 
3 and 4.) 

If we divide the mamma of a female recently confined, 
or who is nursing, through the centre of the nipple, and 
separate the divided portions, we may observe with a 
glass, the direction, number, and form, of the milk canals, 
which are fifteen in number. They are very broad in the 
body of the gland, and sensibly diminish in proportion as 
they are directed towards the nipple where they terminate : 
we can easily squeeze out some drops of milk from them. 
(See PL LXXIX Fig. 2.) 

Nursing may be divided into natural and artificial. We 
term natural nursing, that which is strictly according to the 
purpose of nature : it supposes on the part of the child, the 
direct application of its mouth to some nipple, whence it 
derives its nourishment by the particular act of sucking. 
Artificial nursing is a mode or particular manner of re- 
placing natural nursing, and of transmitting to the child, 



MIDWIFERY ILLUSTRATED. 181 

by artificial means, the food proper to nourish it at the 
moment of birth. 

Natural nursing. Of this we distinguish three species ; 
nursing by the mother, by a stranger, and by some animals. 

Nursing by the mother conforms most to the purpose of 
nature : it needs no precept on the part of medicine, and no 
study on the part of the child : the mother merely presents 
her bosom, and the child immediately grasps it, and in- 
stantly a copious flow of milk follows which is sufficient for 
its nourishment. We know not which is most surprising 
among the phenomena of natural nursing, the precision 
and exactness with which every thing is co-ordained in 
order that this function may be unimpeded, or, the agree- 
ment and kind of sympathy between the mother and child, 
so that one always wishes what the other ardently desires. 

Nursing by a stranger, is, properly speaking, mercenary 
nursing. In this latter case, she who nurses the child is not 
its own mother, but a stranger. This mode of nursing 
is very inconvenient, only, in respect to the bad choice of 
nurses. 

The most general rules to be observed in this respect are, 

A good nurse must be from twenty to thirty years old : 
dark, rather than light, and should present all the appear- 
ances of perfect health, be of a lively character, have a 
good appetite, digest well : her eye should be animated, her 
teeth white, her gums firm, her color rosy, her lips red, and 
her breath sweet. 

Her bosom demands particular attention. 

The mammae of a good nurse should be swelled by the 
milk which fills them, and separated by a well marked 
interval : they should be elongated, and in the form of a 



182 MIDWIFERY ILLUSTRATED. 

bottle : pendent, and inclined slightly outward. Bluish 
striae are easily seen through the light tissue of the skin 
which covers them. 

The nipple should be elongated, a little swelled, and its 
surface covered with a slight moisture, when the child 
ceases to suck. The milk should run easily from the 
mouths of the milk ducts. (See PL LXXVII.) 

The milk itself, examined in drops, on the inclined plane 
of some vessel, must be pearly white, and transparent; 
each drop must run slowly, without separating. When 
carried to the lips, it should leave a slightly saccharine 
taste, and as the taste disappears, the flavor of a filbert. 

When we decide upon giving a newly born child to a 
hired nurse, it need not suck immediately after birth, as 
when the child is nursed by the mother : we must, on the 
contrary, wait until the meconium is discharged, which 
always requires at least one or two days. 

Nursing by the aid of animals is but little used ; it should 
be employed only in those cases where other modes of feed- 
ing children are inconvenient. The animals most fit for this 
purpose are particularly the goat, the sheep, and the ass : 
the size of the teat of the other large domestic animals, 
and their indocility, prevent them from being used for 
this purpose. 

Artificial nursing. Artificial nursing is disadvantageous 
in this respect : being subject to the will, and even the 
caprice, of the persons intrusted with this mode of raising 
the little ones, it presents in this respect a thousand 
inconveniences which natural nursing does not possess. 

We ought particularly to be aware of this fact, that arti- 
ficial nursing, in order to be salutary, should resemble as 



MIDWIFERY ILLUSTRATED. 183 

much as possible, natural nursing ; not only in the qualities 
of the milk, but also in the time of feeding the child. 

There are several modes of artificial nursing. Some- 
times a cup is given to the child (allaitement au petit pot) 
which contains its drink. This mode is very inconvenient, 
and hence the small bottle should be preferred, in the neck 
of which is a long piece of spunge covered with fine 
linen. It is thus presented to the child who, deceived by 
appearances, considers it a nipple. 

Mad. Le Breton, midwife at Paris, has recently invented 
a bottle of a peculiar shape, which seems to combine all 
these advantages. (See PL LXXX. Fig. 8.) 



INSTRUMENTS FOR NATURAL OR ARTIFICIAL NURSING. 

Fig. 1. Breast-pipe. This pipe is made of glass, and its 
design is to enable young females, who wish to nurse their 
children, to form the nipple, and thus prepare them to be 
grasped more easily by the child when born. In order to 
use it, the mouth of the pipe is fitted to the nipple, and 
then the female puts the bent extremity to her lips, and 
sucks it, exhausting the air contained in the bottle, and 
thus forming a vacuum. The nipple is then erected and 
lengthens : by repeating this several days in succession, 
this nipple is so prepared that the child sucks it with 
facility. 

Figs. 2. 3. 4. 5. Nipple shields. All these instruments 
have the form of small hats, and are destined for nearly 
the same uses. Some made of wax, wood, or of gum 
elastic {Fig. 1. 2. 3.), are applied to the nipple, directly 
after the child has ceased to nurse, to preserve it from the 



184 MIDWIFERY ILLUSTRATED. 

action of the cold, especially when it has cracked, or to 
lessen the extreme sensibility, or to preserve it from the 
friction of the clothing, &c. 

The nipple shields {Fig. 4.) have a tip of gum elastic 
perforated with several small holes. They may be used 
where the nipple is excoriated, or has cracked. The head 
of the nipple to which it is applied, softens the gum elastic 
and the milk can pass through the holes in it, and thence 
into the child's mouth. 

This mode is difficult, and generally the child is un- 
willing. 

The nipple glasses {Fig. 5.), are a kind of flattened 
bottle, applied to the mammae of those females who have 
too much milk : they are left upon the nipples after each 
nursing, and they are emptied in proportion as they are 
filled. 

There is a small ring on its edge through which a string 
may be passed, and it can be suspended from the neck of 
the female. 

Figs. 8. 9. and 10, are instruments invented by Madame 
Le Breton. 

Fig. 8 is a real bottle, holding from eight to ten ounces, 
the mouth of which is fashioned in the most convenient 
manner for the child to suck : this mouth is covered by an 
artificial nipple (a cow's teat), which the child grasps with- 
out difficulty, and from which the milk readily flows. 

In order to quicken its flow, and that the child may not 
exert itself, the bottle presents near its base a small circular 
opening, through which the external air enters, which acts 
by its gravity on the liquid, and facilitates the sucking. 

Fig. 9 is a peculiar preparation of a cow's teat, which 



MIDWIFERY ILLUSTRATED. 



185 



may be applied on the mouths of all bottles designed for the 
artificial nursing of the child. 

Fig. 10 also is a new instrument, invented by M. Richer, 
termed a galometer. The object of this instrument is to 
measure the gravity of any milk, and particularly that of 
the female. It is composed of a small metrical cylinder, 
terminated like all instruments which measure fluids, by a 
small hollow ball, which contains a determinate quantity of 
mercury. 

The following is a table of experiments upon the milk of 
the female, with remarks. 



Ages of the females. 



Specific gravity 
of their milk. 



22 to 24 years. 
26 to 28 " 
30 to 32 " 
34 to 36 " 
40 to 45 " 



9| to 10o 



8 to 9 
8 hardly 
6 to 7 
4 to 5 



REMARKS. 



1 . The specific gravity of the milk of a female 
is proportional to her age and not to her constitu- 
tion. 

2. If the milk loses its quality in growing old, 
its specific gravity remains the same. 

3. The milk of a blond is heavier than that of a 
dark complexioned person. 

4. Cow's milk is much lighter than that of the 
female, and its specific gravity also diminishes in a 
ratio with the age, and not with the constitution 
of the cow. 



Milk is the special, and may be called the exclusive 
nourishment of the child during the first year after birth : 
but as in artificial nursing, we are obliged to supply the 
milk of the mother by that of others, we have thought 
proper to form a scale of proportions of all kinds of milk 
which we can use, indicating them by the strength and 
richness of their products. 

At the head is necessarily placed cow's milk, which is 
not only the richest in its products, but also the most abun- 
dant, and which in this last respect, presents all the re- 
sources imaginable. We cannot give it to the child as it 



33 



186 MIDWIFERY ILLUSTRATED. 

comes from the animal ; it is necessary to dilute it in 
proportion to the strength and age of the child. 

When used for artificial nursing, care must be taken that 
it is always procured from the same cow. 

Next comes goat's milk : it is less abundant in nutritious 
principles than cow's milk ; it is nevertheless very advan- 
tageous, either as the primary nourishment of the child, or 
as medicine. In fact, it is used with success in pulmonary 
affections. 

The following is the order in which the other kinds of 
milk must be placed. First, that of the female ; second, of 
the mare ; third, of the ass ; fourth, of the sheep. 

It follows from this, that for artificial nursing, the milk 
of cows and goats should be preferred to all others. 



FINIS. 



RECOMMENDATIONS 



The following recommendations of " Midwifery Illustrated," are submitted 
to those unacquainted with this book. 

Dr. Doane, 

Dear Sir, — I learn with great satisfaction, that you are about to submit to 
the Public a translation of the work of Professor Maygrier on Midwifery, 
The writings of this distinguished author on Obstetrics, enjoy at the present 
time the highest reputation in the medical schools of continental Europe ; and 
his graphic illustrations are so simple and so faithful to nature, as to be of in- 
calculable importance both to the student and practitioner. In my professo- 
rial lectures on obstetrical science and forensic medicine, I found the demon- 
strations of Maygrier of signal advantage, and the very moderate price at 
which your publisher proposes to offer an American edition of this costly 
performance, cannot fail to secure it an extensive patronage. 

JOHN W. FRANCIS, M. D., 
Late Professor of Midwifery and Forensic Medicine in 
Rutgers College, <fyc. fyc Sf-c. 

The splendid illustrations of Midwifery given in Maygrier's large work, 
are admirable in their execution, and essentially useful to the practitioner and 
student Dr. Doane in making a translation of this work, and giving to the 
American public an edition of these fine engravings, will essentially serve the 
cause of medicine, and I do not hesitate to recommend the work. 

EDWARD DELAFIELD, 
Professor of Obstetrics and Diseases of Women and Children, 
University of the State of New Yorh 

I am of opinion, that the translation of M. Maygrier's Midwifery, as pro- 
posed by Dr. Doane, will be a most valuable acquisition to students and 
practitioners of medicine. 

ALEX. H. STEVENS, 
Professor of Surgery, University of New York. 



RECOMMENDATIONS. 

Dr. Doane, 

Dear Sir, — I am very happy to learn that you are engaged in translating 
the invaluable work of J. P. Maygrier, on Midwifery. It is considered in 
France as one of the best works on the subject of which it treats, and, having 
attended the lectures of M. Maygrier, I can bear testimony to the great as- 
sistance afforded by his excellent plates to those who are anxious to acquire a 
profound knowledge of obstetric science. The American student has long 
been in want of such a guide, and there can be no doubt that when presented 
with this treatise in his own language, he will have the best book for practical 
purposes now extant. It was my intention to have made an English version 
of it, but am not disappointed that you have anticipated me. 

Respectfully, 

G. S. BEDFORD, 
Lecturer on Obstetrics, tyc. tyc. SfC. New York. 

I possess the large edition of Maygrier's plates, and think them well calcu- 
lated to aid the comprehension of many manual details in the practice of Mid- 
wifery, of which the beginner of this branch of medicine stands much in 
need. 

Wm. p. dewees. 

Professor of Obstetrics, University of Penn. 

I have seen a specimen of the work and plates of Maygrier's Midwifery, 
translated by Dr. Doane. The specimens of the plates are well executed, 
and a work of this kind is of great use to the student, and also of advantage 
to the practitioner in Midwifery. I think such a work deserves the 
patronage of the medical profession in this country. 

THOMAS HUBBARD, 
Professor of Surgery, Med. Institution of Yale College, 

New Haven, March 13th, 1833, 



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